University program a pipeline to rural medicine
By John R. Wheat
Being associated with The University of Alabama College of Community Health Sciences, I am often asked by community leaders and rural residents with whom we work how we are doing in rural medical care. It is a fair question because CCHS was created in the 1970s and was assigned a mission relating to rural health and medical care, especially to produce rural physicians.
If the "we" in the question are rural Alabamians, it depends on where you live and on your personal resources. Those who live in small towns on the margins of Alabama's economically stable cities, such as Tuscaloosa, Montgomery, Birmingham, Huntsville or Mobile, have physicians available to serve them, provided that they have insurance and transportation. Those living where industry is closing have difficulty retaining local physicians and emergency medical services. Fewer people have insurance, so doctors find it harder to keep their staffs paid and offices open.
Decline of farming
Many rural Alabamians live in parts of the state where agriculture used to be the major economic engine for the community and no replacement industry has been developed. They find local doctors and EMS scarce and often have difficulty with both transportation and payment for medical care in regional cities. Economically depressed communities often must take advantage of federal programs to subsidize health care in order to retain local physicians. Doctors raised in these rural communities are much more likely to serve there.
If the "we" are CCHS programs to produce rural physicians and to improve rural community health, the news is good. We began in the 1970s with a training program for family practice, the specialty most often practiced in rural Alabama. We added medical school training for a portion of the medical students from the University of Alabama at Birmingham to also become The University of Alabama School of Medicine — Tuscaloosa Program. We provide these students a special two-month experience in rural Alabama to study rural family practice and community health. They explore health concerns of rural Alabamians from farms and small towns and needs of rural populations such as homebound elderly, uninsured rural children, and mentally ill. In the past 32 years, 315 family practitioners have completed their residency training here; 54 percent of our graduates are practicing in Alabama.
Keeping pace with need
However, in the last 10 years medical student interest in family medicine waned throughout the nation and in Alabama. Alabama's four medical education programs (in Birmingham, Mobile, Huntsville and Tuscaloosa) have not kept pace with the need for family doctors or rural physicians. But during this same time period, CCHS has become a leader in developing programs to meet the need for rural medical care, programs that prepare and admit more rural Alabama students into medical school with the intention of becoming rural doctors.
Since 1993, through the Rural Health Scholars Program, we have attracted 316 students (26 percent minority) from 60 counties across Alabama to a summer program before their senior year of high school. The Minority Rural Health Pipeline Program has recruited 40 students, mostly from the Black Belt region of the state, to a sequence of summer experiences while attending college. We have admitted 90 students to the Rural Medical Scholars Program, a five-year program to study rural community health and to obtain a medical degree. Together, these three programs create a pipeline of education that prepares physicians for rural Alabama who are leaders in community health.
Choosing familiy practice
Among the first five Rural Medical Scholars Program classes, there was no difference between Rural Medical Scholars and their classmates in rates of passing medical school courses and graduating on time. About 40 percent of Rural Medical Scholars have chosen family medicine compared to 6 percent of their medical school classmates. The first class of eight Rural Medical Scholars completed training and chose practice sites in 2004; five (some 63.5 percent) chose rural practices in Boaz, Centre, Gordo, Jasper and Talladega.
The Alabama Farmers Federation has recognized the value of these programs by establishing an endowment that will fully fund the medical education of one Rural Medical Scholar in each entering class.
Model program should be copied
The medical school curriculum committee of the School of Medicine at UAB and the nationally constituted Rural Medical Educators Group of the National Rural Health Association have determined that the CCHS rural medical pipeline is a successful model for producing rural physicians. They recommend that the model be expanded in Alabama and copied elsewhere. These pipeline programs' directors hope both to expand these programs and to prepare physicians to match better the needs of Alabama's most economically suppressed physician shortage areas. These doctors will help meet the communities' needs through health care, community health leadership and economic development. Each new medical practice brings an economic impact of an estimated $1 million annually to a community.
More to do
We know what to do — the task now is to do more. To do more requires more support, more faculty, more coordination of educational programs, more rural training sites and more scholarships. It requires that we in medical education and state government continue to join with Alabama communities to expand the current rural medical education enterprise to include more students and provide a broader curriculum of rural community health.
CCHS fills a unique role in the state's medical education system. Firmly established on the campus of a flagship university with the resources to integrate several disciplines of study necessary for preparing rural physicians to be leaders in community health, CCHS is designated Alabama's lead medical training site for rural physicians. Without sacrificing the responsibility for providing clinical training to medical students who go on to other specialties and urban practices, we can increase the production of rural physicians by expanding what we have shown to work — a rural medical pipeline to prepare rural students for careers in medicine and community health leadership.
These rural medical programs have demonstrated that selecting capable rural students results in more medical graduates who return to rural Alabama to practice. Now, it is clear that the future of medicine in rural Alabama is in the hands of local communities, who must recruit, encourage and support their students who want to become physicians through this pipeline.
Dr. John R. Wheat is professor of community and rural medicine in The University of Alabama School of Medicine — Tuscaloosa Program, University of Alabama College of Community Health Sciences.