Sometimes a television show can do what a stack of statistics cannot.
The rural doctor shortage reached America’s television screens in 1990, when the pilot of “Northern Exposure” first aired. The story line followed a young doctor, Joel Fleishman, who had run up bills of $125,000 at Columbia Medical School and had no way to pay them. The state of Alaska offered to pay off his debt if he would practice medicine there for four years. Joel, while an unalloyed New Yorker, agrees. … and reluctantly, almost unwillingly, ends up in Cicely, Alaska, population: 839.
Much of the show, including the moose who ambled through the opening credits, was filmed in Roslyn, Washington, population: 889 at that time. This gave the setting atmospheric credibility and Joel’s indebtedness for medical school was also quite believable. His $125,000 debt in 1900 would translate to $227,000 in today’s dollars, which would not be unusual for a 2014 graduate of a big city private medical school.
The story line that initially drew viewers in, though, was not the economics but the culture clash between Dr. Fleischman’s city ways and the often- quirky residents of Cicely.
“Northern Exposure” was fiction, of course, except for the moose, but it contained many of the elements, and problems, of rural medicine that remain today.
The economics problem that gets in the way of attracting doctors to rural practice is probably the easiest to solve, expensive, but it can be addressed directly and effectively. It is as easy as it was in fictional “Northern Exposure.” A state can simply offer to pay off a doctor’s debts run up in medical school in exchange for practicing medicine for a few years in an underserved rural market.
It would be using the state taxpayers’ money to benefit a relatively small number of people, certainly, but it would work, which is a lot more than we can say about some of the other publicly funded projects dreamed up in the public sector.
The economics approach would not be enough to solve the problem, though, for there is more to it than just initial dollars and cents. Dr. Tom Greer is a professor of family medicine at the University of Washington Medical School and co-director of the TRUST program there. TRUST stands for Targeted Rural and UnderServed Track, and is both an educational curriculum path for medical students planning to practice in rural areas and a network that connects students, communities, physicians, and medical school faculty in five states.
These five states, Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) have been working together to address the rural doctor shortage, with the UW providing the medical school.
Dr. Greer says that one of the major factors in a young man or woman’s choice of rural medicine appears to be, “they grew up in a rural area or have formed a strong attachment to rural life through marriage, family, outdoor activities or some other way.”
It is very helpful to know this, of course, because it helps focus recruiting and curriculum efforts. Unfortunately, it also defines how demography is working against us. Rural America’s share of the total population base continues to decline each year, which shrinks the number of likely candidates, too.
Dr. Thomas Norris is the chairman of family practice medicine at the UW Medical School. Family practice is what most rural doctors do, but it also includes family practitioners in urban areas. He agrees that a connection to rural life is the primary factor in choosing to practice there. He adds also, that “the doctors who choose to care for underserved people are usually motivated by a desire to make a positive difference in this world.”
Another factor working against a solution comes from the nature of medical education and, of course, human nature. Medical schools are most often in urban areas and young people are attracted to the excitement of working with doctors and colleagues on the “leading edge” of medical technology and treatment.
One of the ways that the TRUST program offsets the allure of urban practice is by making sure that the connections to rural practice stay fresh through scheduling internships, observations, and classroom work in more rural settings as part of the curriculum.
While most of the factors, and the numbers, seem to work against rural practice, there are two things that still attract young doctors. The first is that family practice, especially in rural areas, offers the opportunity to practice a full spectrum of medicine. This is increasingly difficult to do in urban areas.
The second is that for a physician, providing medical care in underserved areas leaves no doubt that you are needed. And being needed is one of the genuine treasures of life.
James McCusker is a Bothell economist, educator and consultant. He also writes a column for The Herald Business Journal.
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