Surgical residents who completed a year in rural practice were more likely to enter general surgery practice than those who did not. They were also more likely to practice in areas with populations of less than 50,000, an Oregon Health and Science University study shows.
Evidence suggests that a good way to lure young physicians into rural practice is to provide them with that experience while they are medical residents.
A new study out of Oregon this month in JAMA Surgery, for example, finds that exposing fourth-year surgery residents to rural practices increases the likelihood that they will practice general surgery in a similar location, even if their initial plans were to further specialize or settle in more-urban areas.
Karen Deveney, MD, program director for OHSU's Department of Surgery |
The study reviewed the records of 70 surgical residents Oregon Health and Science University in Portland who completed the general surgical residency at OHSU and entered practice since the rural rotation began in 2002. The numbers are small, but the study found that residents who completed the rural year were more likely to enter general surgery practice (10 of 11) than those who did not (28 of 59). They were also more likely to practice in a site of population less than 50,000.
Most residents who completed the rural year (6 of 11) entered residency with a desire to practice general surgery. Of the residents who entered training with a specialty career in mind, four of five who completed the rural year are practicing general surgery, while 13 of 45 who stayed at OHSU's university program for the entire five years are in general surgery practice.
The study's lead author, Karen Deveney, MD, program director for OHSU's Department of Surgery, says a rural rotation exposes medical residents to a "sense of community" that often isn't as well defined in urban areas.
"You have a more long-term relationship with a lot of your patients than is often the case in the higher-urban areas, particularly in a specialty where you have brief encounter to take out the gallbladder and you see them a couple of times and they are gone," Deveney says.
"In a small community you take care of them. You take care of their mother and father. You take care of their kids. You see them in the grocery store. You see them when you're getting your car fixed. You end up having this sense of community and people kind of seek that. A lot of our whole hectic life, particularly in urban centers has become fairly isolated and so, this combats that."
"The other thing is that you feel comfortable with a greater variety of procedures and diseases and things and that gives a sense of accomplishment. Sometimes in the urban academic medical centers we are sort of—brainwashed is too harsh a word—but influenced that you can't know it all and so you should focus more and more on a smaller and smaller area."
"Then you get such fragmentation of care that you become an expert in a small thing but that over the long term is less satisfying because it also gets confining. If someone goes into a rural area to do training and practice they see you really can perform at a high level and have a good capability of taking care of a broad range of problems capably."
Many of the nation's taxpayer-funded medical residency programs, most of which are located in urban settings, have come under fire for their failure to expose residents to rural rotations. Even though 20% of Americans live in rural America, a recent study from George Washington University School of Public Health and Health Services found that only 4.8% of new physicians said they planned to establish a practice in a rural area.
The GW study examined the career paths of 8,977 physicians who had graduated from 759 medical residency sites from 2006 to 2008. The researchers found that 198 of 759 institutions produced no rural physicians during the study period. And 283 institutions graduated no doctors practicing in the Federally Qualified Health Centers that serve low-income or destitute patients in underserved urban and rural areas.
Deveney says the nation's residency programs are creating "such a geographic mal-distribution that the urban areas are saturated and the competition of specialists in urban areas is fierce."
"It's counterproductive, particularly in Midwestern and Western states where there is a large expanse of rural towns and people. The urban programs really need to pay attention to the needs of their state. That is kind of why they were set up in the first place," she says.
Even if new general surgeons practice in exurban or smaller cities, that is still preferable to having a glut of physicians practicing in urban centers. "We used towns of 50,000 as the cutoff in our study but there are some who went out to general surgery practice in smaller towns that are between 50,000-100,000," Deveney says. "Those are still closer to where the real need is than in the middle of Portland or Chicago or Seattle."
Deveney readily concedes that the numbers of residents in the Oregon study who gravitated towards rural settings come nowhere near meeting demand. Even so, every little bit helps, and she says the Oregon rural residency rotation could be a model for other states.
"Our program only produces a small number but if you multiplied that by 250 training programs that each produced a couple that would increase the number," she says.
"Increasing the number of trainees entering general surgery practice in rural areas won't take care of the shortage entirely because we don't produce enough general surgeons every year in the entire country—even if all of them went into rural surgery—to do the job. But between our model within a training program and one or two existing programs that have carved out an actual rural track residency program we're mostly saying 'hey if you do this it will work and here is how you do it.'"
"Anything we can do to give greater exposure to the joys of a more generalized practice will have an effect on redistribution."
John Commins is a content specialist and online news editor for HealthLeaders, a Simplify Compliance brand.