Grady, S.C., was one of the lucky rural communities. Unfortunately, it was fictional.

 

In the 1991 film "Doc Hollywood" with Michael J. Fox, the Porsche Speedster of hotshot plastic surgeon Benjamin Stone breaks down in Grady, and the charms of the community, its people and one woman in particular entice the young physician to hang his family-practice shingle in the rural Southeast.

 

For most small communities across America, luring a physician isn't that easy. Despite the fact that nearly 25 percent of Americans live in rural communities, only 10 percent of the nation's doctors practice there, "and it's actually probably less than that now," said Randall Longenecker, MD, clinical professor of family medicine and assistant dean for Rural Medical Education at the Ohio State University College of Medicine. Longenecker is a spokesman on rural-health issues for the nonprofit National Rural Health Association (NRHA).

 

According to NRHA, a host of challenges conspire to create healthcare disparities between rural locations and their urban counterparts, and the remoteness of some communities is just part of the problem. Lower education and income levels in rural areas compound the issue. In "Rural Healthy People 2010," a project funded by the federal Office of Rural Health Policy, there are 2,157 "Health Professional Shortage Areas" in rural and frontier locations in all the states and U.S. territories compared to 910 in urban areas.

 

Yet this is nothing new. "If you look back in history, it's been 100 years that people have bemoaned the fact that there aren't enough rural doctors," said Longenecker, who is in family practice in Bellefontaine, Ohio.

 

Longenecker was instrumental in 2001 in organizing NRHA's Association of Rural Health Educators, and he is membership chairman of the group. He preaches that educational opportunities in rural settings are the key – two residents each year are added to his practice, and the rotation is for three years.

 

Jason Marker, MD, a rural physician in northern Indiana who's a spokesman on the subject of rural healthcare for the American Academy of Family Practitioners, agreed wholeheartedly that recruiting young docs out in the country means giving them a taste of the unique character that is rural medicine. "About six months out of the year, there's a learner at some level in my office," Marker said. He hosts medical students who want a month's exposure in a rural locale and family-practice residents rotate through his practice. He vigorously welcomes high schoolers shadowing him for health class.

 

In fact, Marker recently recruited one of those rotating residents to his practice. "This is one of the reasons I want to keep on teaching as much as I can. Seeing these doctors in training every year rotate through my practice, I get to keep my eye open for the best and the brightest and the ones who have an aptitude for rural healthcare," he said. Otherwise, he added, when the time comes to recruit, "then you're going to drop a bunch of cash on the problem, and you don't want to do that in a small practice."

 

Marker said he's "not a big-city guy," so the decision to return to his hometown to practice was an easy one. Yet he cited two problems that hinder rural recruiting:

Reversing the trend means ensuring that medical schools and residency programs encourage the rural experience, Marker said, adding that that's an AAFP priority.

 

Longenecker said in that in Ohio there's a Rural Health Scholars Program, which invites students in all Ohio's med schools to an annual retreat. The idea is to "keep the passion alive," he said, and to help the issue gain visibility. Longenecker applauded "pipeline strategies" that reach down even into the middle schools and sell the family-practitioner concept, and he noted that Alabama and Missouri have the two of the best. In Wisconsin, it's WARM, the Wisconsin Academy of Rural Medicine, which keeps med students on a rural track. Then there are communities that take the bull by the horns and offer scholarships in exchange for a pledge to practice in the area. Community hospitals are doing the same thing, he noted.

 

One fear that turns young physicians away from rural settings is inadequate access to top diagnostic tools, yet Tammye Trevino, administrator of USDA Housing and Community Facilities, said distance learning and telemedicine programs target exactly that hurdle. "By providing state-of-the-art telecommunications equipment to link students with teachers and patients with medical professionals, rural Americans, even those living hundreds of miles from a major population center, will have access to the best teachers and the best medical systems," she said. Since its creation in 1993, the DLT program has invested $306 million to fund more than 920 projects in 48 states and four territories. Funds may be used to acquire end-user telecommunications equipment such as videoconferencing equipment needed to provide distance learning and telemedicine services to rural communities.  

 

USDA also provides direct and guaranteed loans and grants for the development of essential community facilities in rural communities, and that includes health care. Of course, critical-access hospitals are a prime component of that program, created by the Balanced Budget Act of 1997. Their cost-based reimbursements from Medicare improve their financial performance and reduce hospital closures. Marker said his local 24-bed, critical-access hospital is a recruiting tool, and that communities working to recruit physicians should nurture the partnership that physicians and the hospital enjoy. "That's a nice thing to have in my backyard," he said.

 

Said Longenecker, "Right now, rural hospitals are quite strapped financially, and the economy has just made things worse. Just in Ohio, several hospitals have declared bankruptcy, and many rural hospitals have closed in the last decade. If it weren't for the critical-access hospital program, a lot more would have gone under."

 

Does it really all come down to salary – that specialists in urban areas make more than family practitioners in a rural setting? Sure it does, but both Marker and Longenecker have something to say about that.

 

Marker said the idea is to bring potential rural physicians into the fold and focus on the positive. "One of our hurdles in family medicine is that we tend to be treated badly by our specialty colleagues. If you're treated badly all the time, you tend to grumble. I don't want to show that to students," he said.

 

So why don't generalists make more? "Our country does not value that anymore. That's my in-a-nutshell answer," Marker said. "We started valuing doing things to people higher than listening to and touching people and working them through the problems of their life. It's just not sexy enough. … Our country has had this happen to it."

 

Here's Longeneckers's take on the issue: "I personally think that family physicians are paid enough, maybe not quite as much as some people think we should be paid, but certainly much more than any of our neighbors in our rural communities. I'm well paid. … My take on it is that the specialists are making too much. Our culture is such that we say we value one thing, but we pay for something else."