Editor’s note: This is the third article in a four-part series discussing aspects of a state and national shortage of primary care physicians. The final article will look at how a universal health care plan might affect the problem. The shortage of primary care physicians is a problem nation-wide, but rural areas are feeling the impact more than urban communities. Alabama’s shortage of rural physicians is a continuing problem, with only 10 of the state’s 67 counties having adequate medical access, according to the U.S. Department of Health and Human Services’ 2008 listing of medically underserved areas. How bad is the shortage? “I consider it severe,” says Dr. John Wheat, professor of community and rural medicine at the University of Alabama’s College of Community Health Sciences and School of Medicine, and director of the Rural Medical Scholars Program at the University of Alabama School of Medicine. “Over the last decade, medical student interest in family medicine has waned throughout the nation and in Alabama. Alabama’s four medical education programs — Birmingham, Mobile, Huntsville, and Tuscaloosa — have not kept pace with the need for family doctors or rural physicians.” The Alabama Rural Health Association classifies 55 of Alabama’s 67 counties as rural, and Wheat adds that the state currently needs 230 more rural doctors to provide reasonable coverage within easy travel distance. “We are nowhere near where we need to be to provide coverage on par with what you get in larger cities,” he says. The decrease in the numbers of rural physicians has occurred for the same reasons as the decline in primary care physicians in all areas – lower salaries, longer hours, and less prestige than higher-paying specialties. “Rural doctors typically end up making about the same amount of money as primary care physicians in cities, but rural doctors generally have to work longer hours and perform a greater variety of services,” says Wheat. “We have physicians all over the state who talk about retiring, but they can’t find people to take over their practices.” In addition, medical school cultures typically do not cultivate a desire for medical students to choose family practice, especially in rural settings. “We don’t have enough students graduating from the four medical school campuses in Alabama to supply the family medicine needs in the state – period,” says Dr. John Brandon, a family medicine physician in Gordo, AL, and medical director of the Rural Medical Scholars Program at the University of Alabama School of Medicine. “Of those, there are a limited number who are interested in primary care, particularly family medicine, and more so in rural practice. It is a cascade effect, and it will take an entire generational and cultural change in our society and in medical schools to make a significant difference.” As a result of fewer rural physicians in Alabama, there are people in some areas of the state who have little or no health care. “In the Black Belt, people have to drive 70 miles to get to a doctor to care for them,” Wheat says. Brandon points out that there is a negative effect not only to an area’s health, when it loses a physician, but also to its economy. The American Academy of Family Physicians reports that one family physician has an economic impact of $776,585 per year to the local community by providing employment and purchasing goods and services. The doctor also generates income to other health care organizations such as hospitals and nursing homes. “Without a physician in place in small towns, it is hard to attract industry to the area,” Brandon says. “Businesses first look at education for K-12 and beyond. Then they look at what kind of health care is available for their employees.” To help address the growing need for rural physicians in the state, Wheat founded the University of Alabama Rural Scholars programs in 1996 for the purpose of recruiting students from Alabama’s rural areas. “Studies have shown that students from rural backgrounds are more likely to live and work in rural areas than those who are not from a rural background,” Wheat says. The programs include the Alabama Rural Health Leaders Pipeline Program, the University of Alabama Rural Medical Scholars Program, and the Auburn University/University of Alabama School of Medicine Rural Medical Program. The Auburn/Huntsville program was launched in 2006. The initiative uses a three-pronged approach. The first prong — The Rural Health Scholars program — introduces 11th-grade students to the University of Alabama through a five-week summer session that includes college courses for academic credit, visits to rural health facilities and meetings with medical school admissions staff. “The pipeline program begins targeting rural students long before they are eligible to enroll, putting on puppet shows and presentations in rural elementary schools to make children aware of the different medical professions that exist,” says Wheat. “Another reason to start early is to motivate rural students to work hard to get the grades that will allow them to enroll in the program down the road.” The second prong – Alabama’s Minority Rural Health Pipeline Program – works with students from underrepresented communities by offering summer classes that augment their undergraduate courses and prepare them for the MCAT. Students can enter the third prong – Alabama’s Rural Medical Scholars Program – in their senior year of college. A five-year combined medical and master of public health degree program, the Alabama Rural Medical Scholars program accepts 10 students each year at its Birmingham and Auburn campuses. Participants begin their master’s degree work as seniors by taking courses in rural community health, epidemiology, health care administration and environmental health. “The Rural Medical Scholars Program gives full medical school scholarships to people who qualify in the form of a loan repayment, if they sign an agreement to practice at least four years in a rural medical community,” says Dr. William Coleman, director of the Rural Medicine Program in Huntsville. “I personally feel this has been a major factor in drawing young people into family medicine in rural Alabama. They graduate from medical school debt-free, which answers the debt issue. These programs place the University of Alabama School of Medicine at the cutting edge of national efforts to educate and promote rural medical students to practice primary care and family medicine in rural areas.” In 2006, the first class of scholars in the program completed residency, Wheat says. “Of the four classes that have completed the program to date, 60 percent chose to enter primary care, and of that percentage, 40 percent chose family medicine. Fifty percent entered rural practice in Alabama.” By comparison, only 6 percent of the overall graduates from the University of Alabama School of Medicine choose family medicine, and only 3 percent of recent medical school graduates nationwide have opted for rural practice. Another pipeline for developing rural primary care physicians is maintained by the Alabama Medical Education Consortium (AMEC), a public state initiative created three years ago, to recruit medical school students from public and private Colleges of Osteopathic Medicine throughout the United States for the purpose of increasing the numbers of medical professionals in rural and underserved areas of Alabama. “It is a 21st Century collaborative model using community-based teaching sites to address the complex national issue of producing quality primary care physicians who practice where they are most needed,” says Dr. Wil Baker, Executive Director of AMEC. “The AMEC strategy is to recruit Alabama college students into an osteopathic medical education pipeline that will provide all components of medical education at selected locations in Alabama and elsewhere.” Baker says that the AMEC pipeline has increased the capacity for medical education in Alabama by 58 percent by partnering with nine osteopathic medical schools to provide more than 100 medical school slots for Alabama students. The students spend their first two years at the respective osteopathic medical school then return to Alabama in years three and four for clinical rotations. Upon graduation from medical school, these students continue their training in American Osteopathic Association certified residency positions in primary fields established at physician offices, clinics and hospitals across Alabama. Baker says that the future of AMEC will continue to focus on recruitment, education and placement of students who will be more likely to pursue primary care medicine as a specialty, providing even more physicians to serve residents of rural Alabama counties. Currently, 357 Doctors of Osteopathy actively practice in Alabama, and 220 of those are providing primary care in 45 Alabama counties. He says the AMEC pipeline will help add to those numbers. “To date, 24 students have completed their medical school education through AMEC’s community-based teaching sites,” says Baker. “Eighty percent of those students have committed to primary care residencies. It will be very satisfying to assess progress three to six years downstream and discover that the mission of AMEC is being fulfilled to the benefit of thousands of Alabama residents.” August 2008