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Can We Fix Alabama’s Rural Physician Shortage?

Can We Fix Alabama’s Rural Physician Shortage?

It takes up to 10 years to train a physician. That decade of training is just one contributing factor for the reason the United States is facing a serious shortage of physicians. Other factors include the growth and aging of the population and the impending retirements of older physicians. While medical schools have increased enrollment by nearly 30 percent since 2002, the 1997 cap on Medicare support for graduate medical education has stymied increases in the number of residency training positions, which are necessary to address the projected shortage of physicians.

A 2019 study conducted for the Association of American Medical Colleges by IHS Markit predicts the United States will face a shortage of between 46,900 and 121,900 physicians by 2032. There will be shortages in both primary and specialty care, and specialty shortages will be particularly large.

Unfortunately, the State of Alabama is already experiencing a physician shortage, most notably in rural areas, and to make matters worse Alabama ranks in the last five of 50 states in health status categories.

Even with Alabama’s medical schools working to educate and nurture a future crop of physicians, there’s no guarantee these medical school graduates will remain here through their residencies or return to Alabama to practice medicine should they complete residencies outside of the state.

In 2018, the Pickens County Medical Society introduced a resolution at the Medical Association’s Annual Business Session to create a planning task force to develop and restore adequate health care manpower with a specific focus on Alabama’s rural areas. The resolution stands as a reminder that while primary care medicine is effective in raising health status, supporting hospitals and improving the economic status of disadvantaged communities, the state’s aging population is also causing an escalation in need for primary care physicians.

“The task force has brought together physicians from across the state with various practice situations to work with the many entities that comprise our health care system,” said Beverly Jordan, M.D., a family and sports medicine physician from Enterprise, Ala., who chairs the task force. “Both long
and short-term goals are being developed, and we look forward to expanding our work to non-physician groups that play an essential role in the development and sustainability of physicians in rural Alabama. A variety of barriers to physician practice in rural Alabama have already been identified, as well as several amazing programs that address those barriers and ideas for innovative solutions.”

Members of the task force met in person for the first time in August 2018 and discussed a number of issues but focused on the importance of fully funding the Board of Medical Scholarship Awards, scope of practice, physician pipeline programs, education and the possibility of GME expansion, recruitment and retention of physicians through meaningful tax credits and rural community support, and start-up business models.

Medicaid Commissioner Stephanie Azar and Dave White from the Governor’s Office joined the meeting to hear the concerns of the task force and take their report back to Gov. Kay Ivey.

“Because this was the first face-to-face meeting of the task force, we had a lot of ground to cover,” said Executive Director Mark Jackson. “Naturally there are a lot of concerns about health care shortages in rural areas, but our goal is a long-term solution. The members of the task force realize this isn’t an easy fix, which is why they were willing to express their concerns openly and honestly to the Governor’s staff.”

This year during the Annual Business Meeting the task force offered a report of its first year’s work including a number of initiatives to improve the rural primary care workforce, new and proposed initiatives, and future recommendations.


What Are We Doing NOW to Improve the Rural Alabama Primary Care Physician Network?

There are already a number of initiatives in place designed to improve the rural physician workforce in Alabama. These have proven successful in the past, yet given the growth trends in population and fewer physicians are choosing to locate to rural settings, these initiatives will not be enough to sustain adequate access to care for our residents living in rural areas:

Alabama Board of Medical Scholarship Awards  Amended in 1994, this legislative program was funded at about $1.4 million in 2018. Funding currently allows about nine recipients a year (full cost of medical school attendance), with a significant waiting list. As a result, 96 percent of recipients practice in Alabama; 98 percent in primary care (78 percent family medicine); 90 percent in rural Alabama; 73 percent continue in their original communities after completing the scholarship obligation.

Physician Tax Credit Act  The State of Alabama allows a state income tax credit of $5,000 for up to five years for a physician or dentist in rural practice. Legislation is currently being considered to enhance the tax credit. The Medical Association staff will report on any changes to this legislation as the Regular Session of the Alabama Legislature continues.

Rural Medical Scholar Program (RMSP)  Since 1996 this program has enjoyed statewide and national acclaim as a successful model for rural college students through medical school. On average, 11 students are admitted to this highly selective five-year medical education program of The University of Alabama and the University of Alabama School of Medicine. The Rural Medical Scholars Program includes a year of study, after students receive their undergraduate degree, that leads to a master’s degree in Rural Community Health and early admission to the School of Medicine. Undergraduates may qualify after their junior year if they have met most of the requirements for their undergraduate major. In the year prior to entry into medical school, students take courses related to rural health and the practice of primary care in rural areas, and participate in special seminars, field trips and community service programs. Since its founding in 1996, more than 200 students have participated in the program, and of the graduates, 81.8 percent practice in Alabama while 62 percent practice in rural Alabama.

Rural Medical Program (RMP)  The Rural Medical Program began in 2005 and is modeled after the RMSP. This five-year medical school curriculum’s sole purpose is the training of physicians to serve in the areas of greatest necessity. RMP is a jointly sponsored program by the Auburn University College of Sciences and Mathematics and UAB School of Medicine Huntsville Regional Campus. The RMP curriculum promotes family medicine by providing for students to attend the annual meetings of the Alabama Academy of Family Practice and the National Student American Academy of Family Practice. Students also participate in the Medical Association’s Governmental Affairs Conference in Washington, D.C. The program has 79 percent of graduates that are family physicians, 90 percent are in primary care practice, and 74 percent are rural.

Early Medical and Other Health Professions Pipeline Programs  Rural Health Scholars, Rural Minority Scholars and others have sought to provide high school and community college student recruitment and guidance. Tuscaloosa’s Rural Minority Health Scholars has had 200 members and 15 have gone to medical school. Of the 650 Rural Health Scholars from 1993-2018, 56 have gone to medical school. These programs are aimed at all health care occupations and serve to raise awareness of medical opportunities for hundreds.

Huntsville Rural Premedical Internship (HRPI)  Since 2004, by bringing college students with rural backgrounds to the UAB Huntsville medical campus for a summer experience including clinic shadowing, didactic sessions, field trips, and medical skill workshops. With 74 percent of available graduates being accepted to medical school (125/169); 67 percent of participants having completed medical school and residency are in primary care; 67 percent are in Alabama with 46 percent rural. Of those in HRPI and a rural track such as RMP or RMSP, 75 percent are rural Alabama family physicians.

Alabama Area Health Education Centers (AHEC)  Started in 2012, five centers across Alabama focus on improving access and workforce in rural and underserved communities. AHEC engages in student recruitment and support and physician education and retention activities, partnering with medical and other health professions schools to link students to positive clinical rotations in underserved areas. Revised HRSA funding directions have decreased support for this level of activity by AHEC, through its centers continue to address these goals through other support. Improved networking, information and digital resources may provide leverage for these important but challenging activities.

Medical School Admissions Committees  Important factors include student recruitment, school policies and priorities for recruiting rural and underserved students, and committee membership (particularly rural and family physicians). The Medical Association can provide opportunities for expanded dialogue with our medical schools about how to increase the number of rural medical students, utilizing successful models from our own state and others. Using these current programs and initiatives as benchmarks, the task force began to work outward searching for changes and new models to reinforce what was already working and expand opportunities for new physicians in rural areas.

“The most important fact about this rural task force is that the Medical Association is stepping up to the plate to address the wide range of problems and challenges facing rural health in our state. That’s a highly responsible and even courageous act. The last time our Association did this was more than 20 years ago, and the outcome was the modern version of the Medical Scholarship Act and our current collaborative model for advanced practice providers such as nurse practitioners and physician assistants,” said Bill Curry, M.D., Dean of Rural Programs for University of Alabama Birmingham School of Medicine and one of the chairs of the Manpower Shortage Task Force. “This time, Dr. Jordan and the Board have taken a comprehensive and long term approach. We’re looking at everything from the physician workforce pipeline – reaching from rural schools through college, medical school, residency, and practice recruitment and retention – to the plight of rural hospitals to the responsibilities of our medical schools and state agencies to partner with communities and professional societies across all that’s involved in rural health. It’s a very full plate, and it’s important to identify initiatives with impact and to set priorities.”

The Next Step

Fact: During the last five years nationwide, applications to and enrollment in medical schools have increased.

Fact: While there is a projected shortage of primary care physicians, there is also a projected shortage of specialists.

Fact: Fixing the physician shortage requires a multipronged approach including innovations in team-based care and better use of technology to make care more effective and efficient.

Facing the facts of a physician shortage is the first part of the battle. The members of the Manpower Shortage Task Force had the opportunity to define new initiatives to begin to create a path to move the state forward and away from a deficit of physicians in rural areas.

Practice Incubator Models  Multiple partnerships involving existing or new practices, health systems and local governments, with or without initial support through the Alabama Board of Medical Scholarship Awards, the National Health Service Corps, or other scholarship programs. The incubator process involves recruitment of mentee doctors (frequently just out of training) to rural practices established by mentors. The mentee then learns private practice and is subsequently enabled to move to another rural location by the mentor or the mentee may simply buy into the existing practice if sufficient growth has occurred. The benefit to the mentor is a return on investment of satellite practices or income realized above the salary of the mentee.

Improved Workforce Database  Traditional sources of information about the Alabama physician workforce include the Alabama Board of Medical Examiners, the American Medical Association physician database, the American Academy of Family Physicians, the National Rural Health Association, County Health Rankings, the Center for Medicare and Medicaid Services, and information from the Alabama Department of Industrial Relations. Recently the UASOM Huntsville Office for Family Health, Education and Research (OFHER) has combined, analyzed and displayed data from various sources into more usable and interactive formats, and the Alabama Rural Health Association has collaborated in this effort also.

Improve and Standardize the Designation of Primary Care Shortage Areas for Alabama  HRSA has established a work directive for all state Offices of Primary Care (PCOs) to establish a state network of rational service areas for identifying local and/or regional shortages and developing rational and reasonable solutions to eliminate identified shortages. The Alabama medical community must be a major player in the development of Alabama’s Rational Service Areas (RSAs). There is a major concern if the Medical Association and the medical community are not involved in the formation of state RSAs, then private practice primary care providers and physician mental health providers and rural hospitals will be left out.

Scholarships  Graduate medical education programs in primary care need more scholarships. Some scholarships expect recipients to enter primary care while others require rural service. Currently, the BMSA is the most successful program in the state, and possibly the nation, for providing physicians to rural areas. The scholarship is repaid by rural service of four to six years depending upon the size of the underserved town.
Changes in Undergraduate Medical Education Students most likely to enter rural practice are those from rural areas. Selecting students from rural Alabama, expanding rural premedical programs, and expanding the rural tracks will provide a larger pool of applicants to the state’s family medicine residencies. Other options include allowing early admission as college juniors providing they achieve predetermined academic and MCAT standards; and placing third-year students with primary care physicians, which serve to increase student familiarity and comfort with the practice.

Changes in Graduate Medical Education  Data shows the physician most likely to practice in Alabama is one who is from Alabama and who attends medical school and residency here. Also, the person who is from a rural area in the state is the most likely to return to a rural area. The most important mission is to fill the current family medicine slots with the Alabamians most likely to enter rural practice. New residency programs are also an option. These programs are beginning to pop up across the state from Madison County to Baldwin County in a variety of specialties.

Transition from Residency to Practice  The final chapter of the process is moving from a residency to a medical practice. The expansion of the BMSA is the surest and fastest method of attracting physicians (which has solid, objective data proving its worth). Out-of-state physicians may be attracted to rural Alabama because of the advantages in cost of living and professional satisfaction. Physicians may move from states ranked as the worst in which to practice medicine (IL, CA, MD, OR, MA, DC, NY, RI, NM and NJ) to Alabama, which was ranked the third best in the U.S. behind NC and TX. (Medscape Physician Survey, 2016).

Targeting the Black Belt Communities  According to the Black Belt Solutions/Community Engagement Subcommittee’s Co-chair John Wheat, M.D., engagement and partnerships among communities and resource agencies for this area will be the lynchpin for its success.

“This population and region desire doctors and other health professionals who understand their life, identify with them, and want to live and practice among them,” Dr. Wheat explained. “It is apparent such physicians are far more likely to be from the Black Belt than elsewhere, their course through medical education must be supported in many ways, that practice facilities must be on par with urban counterparts, that social and professional contexts must be prepared for them, and patients must be able to afford to come to them. Our first and continuing task is to engage the knowledge, trust and commitment of multiple groups with varying perspectives and influences for making changes required to succeed in these efforts.”

Dr. Wheat and co-chair Brittney Anderson, M.D., are originally from Alabama’s Black Belt and have begun reaching into the community to contact local ministers, county commissioners, physicians who grew up in the region, and other community activists with strong commitments to the region for opinions and ideas about how to better serve the area.

“We have been well received and encouraged to continue toward setting up a planning structure that will be inclusive and unify multiple groups and agencies. We look forward to having a planning group that will receive enthusiastic invitations from various Black Belt communities asking us to partner with them in producing and maintaining the health care professionals in their community,” Dr. Wheat said.

The Long Road Ahead…

The Medical Association and the members of the Manpower Shortage Task Force realize there is a long road ahead to finding the best solutions to Alabama’s physician shortage in our rural areas, but we are working toward solutions…and there will be many solutions and many partners to take part in the process.

“We recognized that without a viable rural health system – which has to include either a hospital or a freestanding facility with after-hours and emergency coverage – it’s difficult or impossible to have effective primary care and other services in a rural community,” Dr. Curry said. “The Association’s reaching out to the Alabama Hospital Association and other partners is a huge step, and I hope the regulatory or other changes needed will happen soon.”

Dr. Jordan agreed, adding that help from established physicians is always welcome.

“Our work has just begun, and we look forward to continued efforts to both develop and sustain excellent health care communities in rural Alabama,” Dr. Jordan said. “As we expand our workgroups to include educational, business, political and religious leaders in our state, we welcome the involvement of our physician members. Please don’t hesitate to contact us if you are willing to help – we need you!”

If you would like to be involved with the task force, have questions, or would like to contribute an idea, please email Association Executive Director Mark Jackson.

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Legislation Introduced to Tackle Doctor Shortages

Legislation Introduced to Tackle Doctor Shortages

WASHINGTON, D.C. – U.S. Reps. Terri Sewell (D-AL) and John Katko (R-NY) have introduced legislation that would take critical steps towards reducing nationwide physician shortages by boosting the number of Medicare-supported residency positions. The Resident Physician Shortage Act (H.R. 1763) would support an additional 3,000 positions each year for the next five years, for a total of 15,000 residency positions.

“This week, medical students across the country will celebrate their match into physician residency programs, but many of their peers will be left without a residency due to the gap between students applying and the number of funded positions. At the same time, the United States faces a projected shortage of up to 120,000 physicians by 2030. We need to act now to train more qualified doctors,” Sewell said. “Increasing the number of Medicare-supported residency positions means increasing the number of trained doctors to meet growing demand. It also means giving hospitals and health centers the tools they need to increase access, lower wait times for patients and create a pipeline of qualified medical professionals to serve Americans’ health needs.”

To become a practicing doctor in the U.S., medical school graduates must complete a residency program. However, for the past two decades, an artificial cap on the number of residents funded by Medicare – which is the primary source of payment for residents – has limited the expansion of training programs and the number of trainees.

According to the Association of American Medical Colleges, the United States will face a physician shortage of between 42,600 and 121,300 physicians by 2030. As the American population grows older, the demand for physicians and other medical professionals will increase.

Earlier this year, the Medical Association empaneled the Manpower Shortage Task Force to develop and restore adequate health care manpower in all geographic areas in order to provide quality local health care for all Alabama citizens. Members of the task force have discussed a number of issues including fully funding the Board of Medical Scholarship Awards, scope of practice, physician pipeline programs, education and the possibility of GME expansion, recruitment and retention of physicians through meaningful tax credits and rural community support, and start-up business models.

“Naturally, there are a lot of concerns about health care shortages in rural areas, but our goal with the task force is a long-term solution,” said Medical Association Executive Director Mark Jackson. “The task force and the resolution stand as a reminder that Alabama ranks in the last five of 50 states in health status categories, and while primary care medicine is effective in raising health status, supporting hospitals and improving the economic status of disadvantaged communities, the state’s aging population is causing an escalation in need for primary care physicians. The Association would like to thank Rep. Sewell for introducing the bill and will work closely with her and her staff to help ensure its passage.”

Read the Resident Physician Shortage Act

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Association’s New Task Force to Address Health Care Manpower Shortage

Association’s New Task Force to Address Health Care Manpower Shortage

In response to a resolution passed by the House of Delegates during the 2018 Annual Meeting in Montgomery in April, the Board of Censors formed a new task force to develop and restore adequate health care manpower in all geographic areas in order to provide quality local health care for all Alabama citizens.

The resolution, submitted by the Pickens County Medical Society, stands as a reminder that Alabama ranks in the last five of 50 states in health status categories, and while primary care medicine is effective in raising health status, supporting hospitals and improving the economic status of disadvantaged communities, the state’s aging population is causing an escalation in need for primary care physicians.

The task force had its first meeting the week of July 23 and will meet again on Aug. 14. We will post details as they become available.

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Research: Physician Shortage Likely to Have Severe Impact on Patient Care

Research: Physician Shortage Likely to Have Severe Impact on Patient Care

The United States continues to face a projected physician shortage over the next decade, creating a real risk to patient care, according to new data released by the Association of American Medical Colleges. The latest projections continue to align with previous estimates, showing a projected shortage of between 40,800 and 104,900 doctors.

For the third consecutive year, the Life Science division of the global information company, IHS Markit, conducted a study of physician supply and demand on behalf of the AAMC, modeling a wide range of health care and policy scenarios, such as payment and delivery reform, increased use of advanced practice nurses and physician assistants, and delays in physician retirements. This year’s report extended the date of the projections by five years, from 2025 to 2030, to account for the time needed to train a physician who would start medical school in 2017. The report also includes an expanded section modeling the additional demand for physicians that would be generated by health care utilization equity.

“The nation continues to face a significant physician shortage. As our patient population continues to grow and age, we must begin to train more doctors if we wish to meet the health care needs of all Americans,” said AAMC President and CEO Darrell G. Kirch, M.D.

The report aggregates the shortages in four broad categories: primary care, medical specialties, surgical specialties, and other specialties. By 2030, the study estimates a shortfall of between 7,300 and 43,100 primary care physicians. Non-primary care specialties are expected to experience a shortfall of between 33,500 and 61,800 physicians.

These findings are largely consistent with the 2015 and 2016 reports. In particular, the supply of surgical specialists is expected to remain level, while demand increases. The study also finds that the numbers of new primary care physicians and other medical specialists are not keeping pace with the health care demands of a growing and aging population.

“By 2030, the U.S. population of Americans aged 65 and older will grow by 55 percent, which makes the projected shortage especially troubling,” Kirch said. “As patients get older, they need two to three times as many services, mostly in specialty care, which is where the shortages are particularly severe.”

Expanding on last year’s findings, the new report also includes an analysis of the needs and health care utilization of underserved populations. These data show that if the barriers to utilization were removed for these patients, and all Americans accessed health care at the same levels as insured, non-Hispanic white populations, the United States would have needed up to 96,800 doctors in 2015. Nearly three-quarters of those physicians would be needed in metropolitan areas. This figure is in addition to the projected workforce shortage based on current practice patterns.

“Not only do these utilization equity data highlight the need for the nation to train more doctors, they also demonstrate the importance of a diverse health care workforce. Many of those who underutilize health care — despite their need — are from racial and ethnic minority backgrounds,” Kirch said. “A diverse and culturally competent workforce will enable us to provide the care all Americans need and deserve.”

To help alleviate the physician shortage, the AAMC supports a multipronged solution, including expanding medical school class size, innovating in care delivery and team-based care, making better use of technology, and increasing federal support for an additional 3,000 new residency positions per year over the next five years.

“We urge Congress to approve a modest increase in federal support for new doctors,” Kirch said. “Expanded federal support, along with all medical schools and teaching hospitals working to enhance education and improve care delivery, would be a measured approach to solving what could be a dangerous health care crisis.”

The Association of American Medical Colleges is a not-for-profit association dedicated to transforming health care through innovative medical education, cutting-edge patient care, and groundbreaking medical research. Its members comprise all 147 accredited U.S. and 17 accredited Canadian medical schools; nearly 400 major teaching hospitals and health systems, including 51 Department of Veterans Affairs medical centers; and more than 80 academic societies. Through these institutions and organizations, the AAMC serves the leaders of America’s medical schools and teaching hospitals and their nearly 160,000 faculty members, 83,000 medical students, and 115,000 resident physicians. Additional information about the AAMC and its member medical schools and teaching hospitals is available at

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Rural Medicine at a Crossroads


Editor’s Note: This article was originally published in the Fall 2015 issue of Alabama Medicine magazine

Part 1 – Feeling the Physician Shortage Pinch

Living in a small town means everyone knows everyone, a tip of the hat speaks volumes, and the nearest neighbor may be a mile down the road. Physicians in these communities are often called upon for a variety of reasons from treating flu and pneumonia, to setting broken bones, to delivering babies. Oftentimes, today’s rural physician is a jack of all trades.

There are many challenges to living in an area that may only have one grocery store or gas station. But, when it comes to the health of Alabama’s residents, many rural counties are further struggling with access to proper health care. As older physicians retire, they leave behind shoes that are tough to fill as fewer young doctors are willing to practice medicine in rural areas.

With Alabama’s rural health care at a crossroads, where do we go next?

Alabama’s 5 million residents routinely struggle with some form of access to health care. Whether it’s finding a specialist or one in primary care, there simply are not enough physicians in Alabama, especially in rural areas…and the shortage is projected to only get worse.

“Already having a relative shortage of physicians compared to urban areas, the trend, which is more pronounced in rural areas, of an increasing proportion of the population who are elderly, has increased the need for rural physicians,” said John Wheat, M.D., 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.

Sixty-two of Alabama’s 67 counties have been designated as whole or partial health professions shortage areas, or HPSAs, in which there are not enough physicians to meet the needs of the population. Eight counties have seen their hospitals close, and others are fighting to keep their doors open.

In addition to an older population as compared to urban areas, Medicaid is the primary source of insurance in these rural areas. One-in-four rural residents is eligible for Medicaid benefits, about 10 percent higher than in urban areas. There are many uninsured Alabamians in rural areas who, despite their lack of insurance, still have health care needs.

The shortage of physicians is compounded by the number of older doctors who will retire in the next few years with relatively few young physicians in the pipeline to take their place. This was one of the main reasons the Medical Association worked to pass the Interstate Medical Licensure Compact earlier this year.

“The Compact will allow board-certified doctors with clean records a much faster path to medical licensure in Alabama,” said Buddy Smith, M.D., president of the Medical Association, and a family physician from Lineville. “We want to be able to recruit and attract quality physicians and have them begin treating patients immediately.”

Part 2 – Life in a Small Town

The waiting rooms were packed with nearly every seat occupied on this day as most days for David Arnold, M.D., and Dale Mitchum, M.D. Dr. Arnold, a family physician, and Dr. Mitchum, a general surgeon, work in Geneva County where the population is around 27,000. Dr. Arnold is one of a handful of family physicians in the county, but Dr. Mitchum is the only general surgeon.

Life here moves at a slower pace, with shopping and dining opportunities limited. The challenges of a rural lifestyle require Drs. Arnold and Mitchum to approach their patients and practices in unique ways.

As a family physician of more than 30 years, there’s not much Dr. Arnold hasn’t seen, so he and his staff make sure there is time in their busy schedule during the day for unexpected events that “pop up,” such as cases of sick children or elderly patients or even broken bones.

“Most of my staff have been with me for at least 15 years. We’ve learned to anticipate each other, so our teamwork is exceptional. We wouldn’t be able to see as many patients as we do if we didn’t work so well together,” Dr. Arnold said.

For Dr. Mitchum as the county’s only surgeon, the physician shortage isn’t unique to Alabama. He also treats patients in nearby Bonifay, Fla., and sees how a shortage of physicians anywhere can strain a community’s health care system. As many physicians that have come from his home county of Geneva, he’s seen them leave for a host of reasons to practice elsewhere. Those who stay tend to do so because of family connections.

“It’s hard work,” Dr. Mitchum said. “If you have a relative who is going into medicine who can look to you as a mentor, they can acclimate to the situation. It’s really a nice place to live, but you have to acclimate to the day-to-day slower style of living. It can be culture shock if you’re not used to it.”

Dr. Mitchum understands firsthand about coming back home to take over the family practice. His father, O.D. Mitchum, M.D., was a long-time family physician in Geneva when his son worked as an orderly in the local hospital. After medical school and residency, he came home to stay and eventually practiced with his father for about 20 years before the elder Mitchum retired.

For Dr. Arnold, it was his intention all along to practice rural medicine. The pull of small-town life and the close relationships that often develop between rural physicians and their patients was enough to bring Dr. Arnold to the City of Geneva.

“Now I’m seeing the children I delivered back in the day that have grown up and have children of their own,” Dr. Arnold said. “In these rural counties, the patients are so spread out. Staying in touch with our patients presents its own challenges. I can’t say that we don’t have our own special challenges.”

It’s those “special challenges” and a shrinking number of physicians dealing with them that makes provision of rural health care so different. This is especially true in primary care, where there are fewer students in medical schools across the country choosing primary care as a focus or willing to practice in areas that are designated health profession shortage areas, or HPSAs.

Another challenge for the rural physician, Dr. Mitchum said, comes when a patient needs a specialist. According to him, rural physicians have to deal with all types of problems out of necessity.

“I’m not saying rural physicians are any better at those jobs than physicians in other places, but we deal with those types of things every day. A family physician in a rural setting requires more expertise than one that might practice in an urban setting because we have to be a little bit of all things at all times and do more with less.”

As Dr. Arnold explained, one of his biggest concerns may be access to care, but that’s just the tip of the iceberg. Geneva County has a hospital that’s connected to a nursing home, and he and Dr. Mitchum see patients at both facilities. In addition to the special challenges rural medicine faces, these physicians also have the same burdens of federal regulations to deal with, such as ICD-10, electronic health records, Meaningful Use, etc.

“After seeing patients all day, the next biggest challenge for me is keeping the chart gods happy,” Dr. Arnold said. “Making sure the charting is complete is a huge part of my time when the software required by government regulations will only do so much. The rest is up to me to make sure what goes into the chart is correct.”

Both Drs. Arnold and Mitchum own their practices, and they bear the burden of financing these federal mandates on their own. While these are certainly not easily absorbed by any practice, solo practitioners have an even more difficult time with such expenses. With the current transition to ICD-10, questions remain about reimbursement, delays in payment, and other mandates yet to come.

All three physicians agreed the outlook for rural medicine could be and needs to be improved. The belief that it’s cheaper to practice in a small town is a misconception, they said.

Steven P. Furr, M.D., former president of the Medical Association, and a family practitioner from Jackson, Ala., agreed the regulatory burdens on rural physicians make it more difficult to sustain a medical practice. In fact, Dr. Furr argues the time physicians take to satisfy these federal regulations from Meaningful Use to maintenance of certification to ICD-10, as well as the quality initiatives by insurance companies, negatively affect patient care by overwhelming the physician and staff.

“All physicians are facing these problems, but in rural areas there’s often the lack of staff and training resources to help them migrate through these minefields,” Dr. Furr said.

Physicians enduring the “normal” challenges of practicing medicine and also the special challenges of providing rural care are tremendous assets to the communities they serve.

Dr. Smith stressed that physicians are uniquely situated to help improve both health and the economy, but for rural communities in particular, attracting and keeping them is key.

“When you realize the economic footprint of just one physician is more than $1 million, that’s huge for a small town,” Dr. Smith said. “If you can attract one or two doctors to a rural area, the health and financial benefits to the surrounding area are tremendous.”

Part 3 – From School to Practice…The Making of a Rural Physician

The shortage of physicians is a national problem, and Alabama’s rural communities are certainly feeling the pinch.

According to Allen Perkins, M.D., MPH, professor and chair, Department of Family Medicine, University of South Alabama, one contributing factor for the physician shortage in Alabama could be that medical schools cannot keep up with the health care needs of the state.

“It is clear the overwhelming majority of the medical students come from the urban counties yet the average age of our rural physicians is over age 55. We have an acute lack of mental health services in rural Alabama and yet not training professionals in rural settings,” Dr. Perkins explained.

While not a cure-all for Alabama’s rural health crisis, more physicians is a good thing, and programs to increase the number of physicians in rural areas like the Rural Medical Scholars Program (RMSP) at the University of Alabama’s College of Community Health Sciences and the Board of Medical Scholarship Awards (BMSA) are part of the solution.

RMSP is a highly selective pre-med and medical education program allowing 10 qualified students annually to take graduate level courses, participate in farm field trips, shadow rural physicians, conduct or assist with health fairs and screenings or other community service projects and attend lectures and workshops pertaining to rural community health topics. RMSP is one of several rural health care pipelines in Alabama working to put family physicians into rural areas.

Of the nearly 200 rural Alabama students that entered the RMSP during the past 20 years, about 70 percent entered family medicine and almost 60 percent went on to practice in a rural area. More than 90 percent of RMSP graduates remain in Alabama, yet not all remain in primary care, Dr. Wheat said, as some have gone on to other medical specialties.

Drs. Wheat and Perkins also agree the need for greater funding of the BMSA is key to not only attracting young medical students to the field but keeping them on track for a career in family medicine in Alabama.

The BMSA began in the 1960s as a state-funded incentive program to increase the supply of family practice, internal medicine, and pediatric physicians, and encourages practice in Alabama’s rural medically underserved communities. Several hundred loans have been awarded since the BMSA was created. Students who receive the loans agree to return to a pre-approved medically, underserved community to practice primary care.

“The scholarship board needs to be fully funded,” Dr. Perkins said. “Support for the scholarships that place physicians in rural communities is necessary here.”

Dr. Wheat said he feels the medical schools do their part to train the students, but the scholarships also go a long way to getting the students into the schools. He said the Medical Association’s work to keep and increase the amount of scholarship money available each year helps students decide to stay and practice in rural Alabama.

“More than 90 percent of the first 30 RMSs who chose rural practice were recipients of this [BMSA] award,” Dr. Wheat said. “We see this playing out to the benefit of communities. With a bit more effort on the parts of each of our partners, even the most persistently underserved rural areas of the state will see positive results.”

Family physician Terry James, M.D., said the RMS program was invaluable to him. “I might have had to make different arrangements early on in my career,” Dr. James said. “If not for the RMS, I don’t know if we would be addressing the health care shortage in rural areas at all. I think it goes a long way to fill that void.”

Outside of the state’s two allopathic schools – The University of Alabama School of Medicine and The University of South Alabama College of Medicine – the state has two new osteopathic schools, the Alabama College of Osteopathic Medicine (ACOM) in Dothan, and the Edward Via College of Osteopathic Medicine (VCOM) in Auburn.

“For a state the size of Alabama to have four medical schools is a very big deal,” Dr. Smith said. “Graduating more medical students is a piece of the puzzle and we are very glad to have these two new osteopathic schools here in Alabama.”

Osteopathic medicine is fast-growing with the number of D.O.s having increased more than 200 percent in the past 25 years. Estimates indicate there are more than 92,000 D.O.s practicing in the United States and 540 are in Alabama.

ACOM’s first graduating class will be May 2017, and according to Dean and Senior Vice President Craig J. Lenz, D.O., FAODME, expectations are high for these third-year students who are just now finishing their clinical experiences. According to Dr. Lenz, the real test will be to see how many ACOM graduates come back to their rural beginnings.

“Dothan may not seem like a rural area, but from a medical care point of view, we are. It’s primary care; it’s family medicine; it’s general internal medicine…those are the defined specialties where the need here is the greatest,” Dr. Lenz said.

VCOM-Auburn is also getting its footing and hopes are equally high for the school’s first crop of students. VCOM is a private college that is part of the Edward Via College of Osteopathic Medicine system of campuses across the South.

Gary Hill, D.O., VCOM-Auburn’s Associate Dean for Clinical Affairs, believes more D.O.s entering rural medicine can help solve Alabama’s physician shortage.

“Much misconception about osteopathic medicine is a result of lack of exposure to the osteopathic profession and physicians,” Dr. Hill said. “Many of the old arguments have vanished as osteopathic physicians now have complete practice rights in every state and are fully recognized and accepted in the U.S. armed forces.”

Dr. Mitchum said while the need for more physicians in rural areas is immediate, the solutions may take more time.

“We have a real need here,” Dr. Mitchum said. “More funding for scholarships and gearing residency programs for rural health care should be a priority. We require more expertise than one that might practice in an urban setting because we have to be a little bit of all things at all times. To do that properly, young physicians need extra training, which means we need better funding for scholarships and opportunities. That begins in the schools.”

Part 4 – Rural Medicine…Medical Association Seeks Solutions

Not just sustaining rural medicine in Alabama but actually moving it forward will require the support and buy-in of multiple entities, including the state’s medical schools, state lawmakers and even the communities where the need for medical care is greatest. Training and residency programs must encourage and prepare those willing to serve rural patients to do so, and state-sponsored scholarship programs that help defray the expense of a medical education are a significant part of that. But there’s another very big piece to the rural medical puzzle.

In many counties lacking significant industry or large employers, Medicaid is the most common form of insurance. As Medicaid reimbursements barely cover or don’t at all cover the cost of providing that care, rural practices’ ability to keep their doors open seems under constant threat. just sustaining rural medicine in Alabama but actually moving it forward will require the support and buy-in of multiple entities, including the state’s medical schools, state lawmakers and even the communities where the need for medical care is greatest. Training and residency programs must encourage and prepare those willing to serve rural patients to do so, and state-sponsored scholarship programs that help defray the expense of a medical education are a significant part of that. But there’s another very big piece to the rural medical puzzle.

Alabama has historically offered some of the most meager benefits yet highest qualification thresholds in the nation for its Medicaid program. This leaves many individuals who would otherwise qualify for Medicaid in another state unable to under Alabama’s plan, driving up the rate of uninsured residents, estimated to be close to 750,000 people statewide. But lack of insurance doesn’t stop many rural physicians like Dr. Mitchum from treating a patient even though he must absorb the cost of that treatment entirely, further burdening his practice.

“Every time I hear where we have people without health care, I cringe,” he said. “We do a lot of charity care because we don’t turn away someone in need.”

With higher numbers of uninsured and Medicaid patients in rural areas and with practice visits increasing, Dr. Smith said as far as the Medical Association is concerned, two things the Governor and Legislature could do to improve the outlook for rural medicine are increasing all physicians’ Medicaid payments to Medicare levels and providing Medicaid coverage to the working poor.

“Raising payments rates for Medicaid will cost the state some funds in the short term but should save considerably more over the long term as the anticipated increased access to medical care allows patients’ health to be better managed,” Dr. Smith said. “Untold Medicaid dollars could be saved by preventing costly hospitalizations and long-term care stays whenever possible, in fact that is one of the chief goals of Alabama’s fledgling Regional Care Organization program. The RCOs need enough doctors of all specialties participating so the frequency of those types of costly stays can be mitigated.”

Dr. Smith said the sooner state officials act to address the issue of insurance coverage for the working poor the better.

“Without health insurance, not only are some of these individuals who would qualify for Medicaid suffering but the cost of care provided is borne by the entire health care community,” Dr. Smith said. “It is my hope the Governor and Legislature would work swiftly to tackle this issue.”

While additional funding for scholarships and training, recruiting and attracting more physicians willing to locate in rural areas can go a long way, these alone cannot solve Alabama’s rural health challenges. Dr. Furr said he still believes other incentives are needed to retain physicians in rural areas.

“Whether that is debt service, some type of reduction in income taxes, not just for those who initially come out to practice, but also for those who continue to stay, or perhaps some kind of protection against medical liability for those who practice in underserved areas,” he said.

Delivery of rural medicine is about the ensuring the viability of the people who make up rural communities, Dr. Smith says, mentioning that large employers and economic developers often review an area’s education and health care systems in determining where to next locate a project.

The physicians who call these communities home are vital to rural Alabama’s future, he believes.

“Rural medicine is indeed at a crossroads, but rural communities themselves are as well,” Dr. Smith said.

“What happens in the next several years will determine the fate of ‘country doctors’ and – I think you can say – their patients, too. It’s my sincere hope that we’ll look back in a decade and see the present as just another mile marker, not the end of the road.”

Article by Lori M. Quiller, APR, director of communications and social media

Posted in: Uncategorized

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