New jobs: training rural health care scholars
A looming shortage of primary care physicians is occurring at the same time the nation is experiencing a growing aging population, increases in people who are obese and have chronic health conditions, and more rural and underserved areas with limited access to a doctor.
The Association of American Medical Colleges estimates a shortage of 21,100 to 55,200 primary care physicians by 2032. Though a record-high number of primary care positions was offered in the 2019 National Resident Matching Program, also called "the Match," a record-low number of fourth-year medical students opted for those positions, according to Kaiser Health News, a publication of Kaiser Permanente.
The Match is a nonprofit organization that pairs fourth-year medical students with residency locations for their chosen specialty after graduation. The three key primary care fields are internal medicine, family medicine and pediatrics. Of the 8,116 internal medicine positions offered this year — the highest number on record — just 41.5% were filled by seniors from U.S. medical schools. The trend was similar for family medicine and pediatrics, The Match reported.
Kaiser Health News reviewed data from The Match and found the number of U.S.-trained MDs who chose primary care positions for their residencies has been falling since 2011.
"I think part of it has to do with income," said Mona Singer, CEO of The Match. "Primary care specialties are not the highest paying."
Osteopathy and orthopedic surgery are a couple of the specialties that are attracting residents. A recent Medscape survey of physician salaries found that orthopedic surgeons earn the highest annual salaries at $482,000. In comparison, internal medicine physicians earn an annual average of $243,000, family medicine doctors make $231,000 and pediatricians earn $225,000 per year on average.
As med school students measure their student loan debt against their potential salary and ability to pay that debt off, other factors come into consideration as well. The Medscape survey found that 80% of internists responded that they spend at least 10 hours per week on electronic medical records and other administrative duties.
Loan forgiveness programs are often cited as a means to encourage medical students to become primary care physicians and practice in rural and underserved areas. Oregon Health & Science University's third-year medical students are required to participate in a Rural and Community Health Clerkship, primarily in family medicine, and can explore opportunities for loan forgiveness if they decide to practice in rural areas after graduating.
Another solution is to allow physician assistants and registered nurses to provide some of the treatment that previously only MDs could administer. OHSU's Oregon Rural Scholars Program offers a program specifically for physician assistants who want to practice in rural areas.
With a dual aim of growing the number of primary care physicians and increasing diversity within Oregon's medical community, OHSU in 2017 initiated the Northwest Native American Center of Excellence in partnership with the Northwest Portland Area Indian Health Board and Portland State University.
As part of that partnership, OHSU offers the Wy'east Post-Baccalaureate Pathway, a 10-month program that serves as an alternative to the traditional medical school admissions process. It includes a mix of science and public health coursework, preparation for the Medical College Admission Test, research, study and self-care skills, and community health service with Oregon tribes. When participants complete the program, they are conditionally accepted to the OHSU School of Medicine. Six members of the program's inaugural class will attend the university this fall.
"We're looking for American Indian and Alaska Native students that others say aren't good enough for medical school, and we're proving them wrong," said Erik Brodt, MD, the center's director and an assistant professor of family medicine.
Jasmine Curry, who spent part of her childhood on the Navajo Nation, is one of the students who completed the program and will start medical school in the fall.
"It's everything my family and I have ever prayed for," she said. "Our families are so proud of us. We're going to be the first doctors in our family. We know how it is on the reservation. We can help our community overcome those challenges. Coming from the same background, we will be culturally competent doctors for Native patients."
In addition, OHSU recently received a grant in partnership with the University of California, Davis, to expand access to health care between Portland and Sacramento through a network of teaching hospitals and clinics in mostly rural areas. The five-year, $1.8 million grant from the American Medical Association will allow the medical schools at both universities to establish an education collaborative called COMPADRE, short for California Oregon Medical Partnership to Address Disparities in Rural Education and Health.
Over the next several years, COMPADRE will place hundreds of medical students and residents to train under faculty and community physicians at 10 health care systems, 16 hospitals and a network of Federally Qualified Health Center partners throughout northern California and Oregon, according to OHSU.
Students and residents will provide services in seven medical specialties, and 10 OHSU residency programs will be directly involved. These include the internal medicine and family medicine residencies at OHSU and Tuality, family medicine at Klamath Falls, and the OHSU emergency medicine, general surgery, ob-gyn, pediatrics and psychiatry residency programs.
COMPADRE's main goals are to address health care workforce shortages in rural, tribal, urban and other communities that lack resources; increase access to health care providers; and improve the health of patients from ethnic and racial minority groups who are disproportionately affected by certain conditions.
"Our responsibility as a medical school is not only to train outstanding physicians, but also to train physicians who meet the needs of all our communities," said Sharon Anderson, MD, dean of the OHSU School of Medicine. "This grant provides the resources and framework needed to build on our existing efforts in an international and coordinated manner so that we have more and even clearer pathways for students and trainees motived to serve where they are most needed."
When the two institutions learned of the AMA's new effort to reimagine residency training, each considered the most difficult problems facing the medical education system. These include physician burnout, students being unprepared to transition to the next phase of graduate medical training, workforce shortages, and health disparities in rural and underserved communities.
George Mejicano, MD, the medical school's senior associate dean for education, is principal investigator for the COMPADRE program and one of five physician leaders who will administer it.
"With our expanded network in Northern California and all of Oregon, we are really excited about the impact we can have in partnership with underserved communities," he said.
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