Rural Pipelines Versus Long Term Obligations
Generic expansions nationwide can be expected to result in no change from the 9% of physicians found in rural areas. To few remain instate, choose needed locations, and remain instate in needed locations.
Voluntary pipelines are still limited by lack of specific focus. Voluntary pipelines are based on the theory that improvements in admission and training and family medicine choice will multiply the result for higher percentages instate in the desired primary care or rural or underserved outcome. Multipliers do work, but represent small relative changes.
Rural pipelines applied nationally can deliver about 20% instate rural practice location. This is better than 3% instate most needed rural for generic expansion, but is still not optimal. Lack of specific instate practice retention and lack of career choice for specialties suitable for rural location limit desired outcomes. Voluntary choice allows career choices outside of family medicine (FM), the only specialty choice that multiplies rural location significantly (triple). Even when choosing IM, surgery, ortho, and ob-gyn the US MD graduates have been subspecializing rather than remaining in the general careers. Instate rural proportions of graduates are single digit for the average and for most state medical schools in the US.
Family medicine tracks linking medical school to residency training can deliver 30 – 40 percentage points of instate rural at least for the first half of a career (the limits of data on such tracks). After 7 years instate with additional time likely prior to admission, the impact on practice location instate is strong. Drift out of state is likely to reduce this proportion over the second half. The rural contribution indication overall in areas such as accelerated tracks has been 40% rural. The family medicine model also addresses small and isolated rural locations. For example the FP to nonFP ratio for U of KS grads indicates a 16 times multiplier for small and isolated rural). Those choosing KS and family practice have characteristics that facilitate optimal health access placements.
Family medicine tracks do not address the other half of rural workforce needs such as general surgeons, ob-gyn physicians, orthopedists, anesthetists, urologists, and general types of cardiology, GI, etc.
Long Term Obligations
The contributions of voluntary models pale compared to long term obligation models. Long term obligation models as illustrated by Jichi in Japan (Matsumoto) can deliver 70% instate and at least 50% instate rural workforce over a career. Over half of this contribution is up front by the 8 year design of the obligation. Such a design also addresses the specialties needed beyond just family medicine.
The challenges are not small for a long term obligation. Iron-clad contracts, informed consent, and interstate or federal compacts are required. States such as Montana are making specific contracts to assure return to Montana after training - by design. Also protections are needed for those under obligation - of course much of primary care workforce needs protection from marginal treatment under the current primary care design.
Medical schools such as Jichi have a cohort effect with all graduates heading to the same types of practices. Japan has implemented commitment tracks in public schools in all 47 prefectures. There will be similar obligations but the cohort effect is likely to be less. Of course Jichi graduates have been leading many of these efforts.
Commitment tracks themselves are a useful admissions tool. Rather than candidates for medical school claiming all types of service, rural, small town, or family practice interests - they would be known as willing to sign the obligation contract or not. This might help the admission committee choose other candidates more likely to remain instate and in careers most needed by the state.
The estimates using rural workforce years after graduation indicate 20% of a career instate and rural or about 7 rural instate years per graduate for 28 per year in a pipeline design with voluntary choice
This compares to compared to 50% instate rural or 17 years spend instate rural in a career using the long term obligation.
With 8 long term committed rural graduates for 8 years and decreasing down to 3 after age 54, a state can count on at least 38 rural physicians at any given time 30, 50, or 70 years later - by design. If the output seemed to be falling short, the obligation length could be increased - again resulting in no increase in cost with a specific increase in rural outcomes. Ten year obligations would likely increase yield to about 44 rural physicians.
Voluntary methods are regressive under US policy designs. Failures of voluntary designs require more generic expansions resulting in substantially more costs for no better primary care result (or less result). Pipelines require increasing maintenance costs across each of 5 or so segments not counting support of rural training sites if included. Funding must be injected to improve the yield across each segment - yields that have been declining already. Long term obligations are selected by those that have every incentive to shape their training for their first 8 years of practice - rural instate practice.
For most of my career I have promoted pipelines. Objective analysis indicates that pipelines only worked prior to 1980 when just about anything worked - by designs that increased spending in primary care, rural, and underserved areas. Recovery of rural workforce, underserved workforce, and primary care workforce will require specific efforts. Assumptions have not worked for 30 years with more to come.