While many physicians get to know their patients at a deeply personal level, relatively few get stopped at the store to talk shop while they’re buying milk. But that can be part of everyday life for physicians in small, rural communities across the country.
“When you’re a rural physician, you bump into your patients everywhere,” said Jesse Van Maanen, MD, a general surgeon at Mahaska Health in Oskaloosa, Iowa. “I’ve looked at plenty of wounds in the aisles of Walmart.”
While this type of small-town charm appeals to some doctors, there is now more demand for rural physicians than supply. The nationwide physician shortage has hit rural counties particularly hard. In Iowa, for example, 97 out of 99 counties are classified as health professional shortage areas, according to the Iowa Medical Society.
To address the need to close the health care gaps in rural communities, the University of Iowa Carver College of Medicine established the Carver Rural Iowa Scholars Program (CRISP). The program focuses on building pathways for rural physicians by enlisting medical students who are interested in practicing in small towns.
The University of Iowa Health Care, which includes the Carver College of Medicine, is a member of the AMA Health System Program that provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
About 10 years ago, CRISP was launched to help address the pressing need for more primary care physicians and other specialists in rural parts of Iowa. It comprises rural medicine-specific curriculum, mentorships, resources and even financial incentives.
Building pathways to rural medicine
While the program draws students from all backgrounds, many of the participants come from small towns themselves.
“I grew up in a small town of about 250 people in North Iowa,” said Shea Jorgensen, MD, an alumna of the program. “I knew I wanted to practice family medicine in a small town and be able to take care of the community.”
Today, Dr. Jorgensen is a psychiatrist and the chief medical officer at Prairie Ridge Integrated Behavioral Healthcare in Mason City, Iowa. Although her clinical focus shifted from family medicine to psychiatry during medical school, Dr. Jorgensen’s vision of serving patients in a small town never waned, thanks in large part to the training and guidance she received in the Iowa program.
The program offers medical students a distinct career path. It includes required rural health rotations during clinical years, as well as coursework tailored specifically to rural health care. For example, there is an agricultural medicine didactic program that covers topics like intoxications of herbicides and pesticides and agricultural machinery safety.
It also has a strong mentorship component. Medical students in the program get paired up with rural physician mentors. This offers students a bird’s-eye view of the challenges and benefits of working in these communities, as well as a mentor to guide them down the path.
Learn how the AMA is pursuing policies that can reduce rural health inequities nationwide.
Offering hands-on experience
One unique part of the program is its focus on immersive shadowing. After the first year of medical school, students in the program shadow physicians in rural communities for four to 10 weeks. This gives them a firsthand feel for the communities, the everyday work and the resources available.
“Not all CRISP students are from small towns, so this allows them to see different lifestyles and ways of life,” said Michael Maharry, MD, who directs the program and also is associate professor of family medicine at the Carver College of Medicine. “It also helps them see that medicine can be practiced well in these communities.”
For Dr. Van Maanen, also a program alumnus, the shadowing program was a welcome change from the lectures, memorization and exams that dominated his first year of medical school.
“When you start med school you think: Now I’m going to see patients, learn things firsthand and get my hands dirty—and then you sit in a classroom for two years,” he said. “But with the CRISP program, I got to do some hands-on work early on in med school. I got to see surgeons work and assist them. That relit the fire in me … and it spurred my excitement.”
In addition, medical students who go through the program, do their residency training in Iowa and return to practice in the Hawkeye State get $20,000 a year for five years to put toward student-loan repayment.
Discover how the recipe for more rural physicians is more exposure in residency training.
Addressing health inequities
One of the biggest benefits of practicing in a rural community is the ability to make an impact on a community’s overall health more quickly—without as many bureaucratic systems to navigate and hoops to jump through.
For example, Dr. Van Maanen’s capstone project as part of the program focused on colon-cancer screening rates in rural communities compared with urban communities. His research focused on why the average rural patient has more chronic disease, presents with higher-stage colon cancer and has less complete screening than the average patient in an urban setting.
He examined colonoscopy rates and how many colonoscopies it took to find colon cancer in the hospital he worked at in Oskaloosa, Iowa, compared with national colon-cancer screening rates. Ultimately, his research revealed that rural communities needed more education, and screenings needed to start earlier.
“It opened my eyes to some of the disparities in rural communities,” Dr. Van Maanen said. “But they weren’t unaddressable disparities.”
After Dr. Van Maanen completed his residency and started practicing, he immediately jumped in to help work on initiatives to improve colon-cancer screening rates in his community in Oskaloosa. Among other things, he organized patient education and outreach, including men’s health events focused on getting farmers out of the fields and into their doctors’ offices when they needed it.
And these efforts paid off. “Getting the word out and teaching people why colon-cancer screening is important really drove up the screening rates, which is now driving down cancer rates,” said Dr. Van Maanen.
Specializing in everything
One of the biggest challenges—and opportunities—in a rural health setting is getting a chance to treat a bit of everything.
When Dr. Jorgensen finished her psychiatry residency, she was used to having access to the full range of psychiatry subspecialty clinics and units.
“But when I came to Prairie Health, I was the only psychiatrist,” she said. “So, the biggest transition for me was coming from a place that had a subspecialty for everything to a place where I had to wear a lot of hats, serving in all those roles.”
But Dr. Jorgensen noted that serving as the only psychiatrist in town has allowed her to truly embed herself and the behavioral health center into the fabric of the community.
She and other mental health professionals at the center are highly accessible. They go into the community to help as many people as possible, caring for patients at the center, in their homes, at homeless shelters, in residential facilities and even in jail.
“We’re embedded within the community in a way that I didn’t feel at a big university program,” Dr. Jorgensen said. “In that setting, patients came to see us in the hospital, and that’s who we treated. Whereas now, I’m within the community and treating the community, which allows us to help our patients most.”
For Dr. Van Maanen, the opportunity to serve a wider patient population was one of the draws of being a general surgeon in a rural community.
During training, “I wanted to stay general so I could do a lot of things,” he said. “In a small town, it behooves you to have a broader skill set because you have a more variety-filled practice than a specialist. Small towns need physicians who can do a lot of things well and then also understand when it’s appropriate to make a referral to a specialist.”
Collaborating with large systems
In addition to making small towns healthier, nurturing the rural physician workforce is critical to supporting the overall U.S. health care system.
Specifically, when rural physicians are providing high-quality care to their communities, it relieves the strain on larger health care systems and academic medical centers.
“We don’t want big hospitals overwhelmed and overrun with things that can be cared for locally,” said Dr. Van Maanen. “If those physicians are bogged down by every appendix, hernia, gallbladder and so on, they’re not going to be able to deliver the high-level, ultra-specialized care they need to. And then those patients who are traveling a long distance to see a specialist will have their care delayed.”
Therefore, it’s vital to have a healthy collaboration between smaller community physicians and larger systems with more specialties.
“We help them by taking care of all the things we can, and then we reach out to them when our patients need something more high level,” said Dr. Van Maanen. “Having a big health system working collaboratively with smaller systems scattered around it is how health care should be. And that good collaboration is what’s best for patients.”
The AMA has developed policy to address and eradicate the rural physician shortage. Many of the interventions the Association is calling for start in medical training.
Among the policy’s aims is to work with stakeholders in medical education “to consider adding exposure to rural medicine as appropriate, to encourage the development of rural program tracks in training programs and increase physician awareness of the conditions that pose challenges and lack of resources in rural areas.”
