Rural General Practice

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Conventional wisdom states that we have a shortage of physicians and more is better. A more careful look suggests that the problem is more of a mal distribution of physicians. We suffer a scarcity of primary care physicians. We need more of them in rural communities. Medical educators face both of these problems. The solutions are difficult without better insight into the challenges of both primary care and rural practice. The first problem is lumping pediatrics, internal medicine and family practice into the same category with family practice. Even OB/GYN wants to be considered primary care for women which adds to the confusion. General practice is still general practice. Calling it family practice as a specialty does not make it a specialty and therein lies a problem with identity, prestige and self image. Medical students soon sense this disparity. Thinking of it, however they may, students choose the specialties, and that perpetuates the problem with both distribution of health care and the competence level of those who do choose general practice or family practice. The intellectual filter works against both distribution and competence in rural areas.

Then what is the solution? Sadly, the one that prevails is the formation of a sub prime provider who acts as more of a technician following protocols and algorithms. He or she is glad for the opportunity, and works semi supervised in structured, mostly in public health or native corporation clinics in a team setting. On the surface this sounds good. The problem is in recognizing critical problems that do not fit the protocols and the distance to a center that handles the more difficult case. In reality practicing in any kind of isolation without multi specialty support requires more of a supper physician, rather than a lesser one.

The steps towards motivating the better talented physicians to undertake a rural practice from a clinical viewpoint are several. First, there must be prestige and assured remuneration sufficient to attract the best physicians and their families to live in a rural community. Forgiveness of medical school debt and tuition will not cut it. The only way I see to accomplish these two things is to extend the residency program to four or five years with extensive time spent in the various specialties to the extent of gaining a core competency in each and with extensive clinical experience in each. In addition these young doctors need the basic tools of genomic and proteomic research, biotechnology, computational biology, epidemiology, public health and bioinformatics leading to a PhD. In other words a supper physician. 

Having created a physician for all seasons, the rural practice clinic must match the capabilities of this now highly trained generalist. Here is where government in partnership with the university and the clinician can achieve what the one cannot. The university can focus its considerable computational, statistical, bioengineering, business and law capacities to create a state of the art network of rural clinics in not just a few but all of the underserved areas of the state. The university can additionally provide nursing, student, intern and resident support. The government presumably the state government must provide adequate funding for construction and implementation with the expectation of a payback from Medicaid and Workman's Compensation services more adequately and affordably provided. The physicians would be salaried giving their families an assurance of income and additionally receive a percentage of the fee for service clinic income. 

Such would be a partnership in which each participant contributes and gains more than any one of them acting alone. Underserved communities and all parties benefit.