The critical challenges that are associated with rural workforce development remain a significant issue in America. We have an obligation to explore the best ways of caring for the underserved rural population. Currently we have a health professions crisis unfolding. The federal government projects a shortage of over 20,000 primary care physicians in rural areas by 2025 (Nielson, et. al., 2017).
How can we guaranty that excellent health care is available for everyone? What are the most effective and useful pathways to insure professional competence and the acquisition of essential resources? We know and continue to be aware of the fact that evidence based rural workforce policy is an enduring challenge (Wilkinson, 2003). Ongoing infrastructure support remains inadequate (Lyle, 2002).
Unfortunately, the stigma associated with pursuing behavioral health evaluation and treatment is heightened in small cohesive rural communities. Within this context there are a limited number of mental health professionals to provide essential mental health care. Privacy and confidentiality are always paramount and yet more difficult to insure within the rural context. Miller (2011) has highlighted some of the essential clinical, professional and social challenges of practicing rural medicine. She argues that complicated interpersonal dynamics occur in sparsely populated areas where privacy is hard to come by. Being the sole medical resource for a community potentially can lead to isolation and physician burnout.
Inequities between rural and urban health will grow unless we ameliorate the situation. In 2010 the Patient Protection and Affordable Care Act and other federal legislative fund initiatives were developed to recruit physicians to rural areas and decrease geographic inequities. Mareck (2011) argues that the federal government has been developing programs to increase the desirability for physicians to pursue careers in rural medicine. Area Health Education Centers (AHEC), Federally Qualified Health Centers (FQHC) and the National Health Service Corps (NHSC) have included scholarships requiring rural medical service as a payback. The goal of providing community driven patient directed comprehensive, culturally competent quality primary care has also been highlighted in the growth of mental health telemedicine. Between 2004-2014 the annual growth rates in this area have reached 45% (Mareck, 2011). In terms of medical education and medical residencies and fellowships, rural training has been quite limited in scope. For example, we know that 99 percent of residencies are located in urban and suburban settings.
Older patients comprise one half of all hospital admissions in rural settings (Nielson et. al.,2017) where older patients in urban settings account for just 37 percent of hospital admissions. This may be explained in part by the fact that older patients in rural communities also suffer from multiple chronic diseases and their primary care physicians often do not have the support of sub-specialists, emergency physicians and hospitalists. It is a vicious cycle that involves primary care physicians struggling with medical breadth, depth and courage to perform medical procedures outside of their comfort zone (Miller, 2011). This, in addition to primary care physicians having limited access to sophisticated medical technology. Treating sicker patients with complex issues in rural settings therefore can be frustrating. Another determinant of health and wellbeing is rural poverty. Rural patients often travel farther for their medical care, struggle with social isolation and the lack of access to affordable nutritious food and medicine (Nielson, et. al., 2017).
Patients resistances to obtaining quality care at times can feel insurmountable and are associated with feelings of instability, anxiety and helplessness. In 2004 Worley used the powerful image of rural communities always being one doctor away from a crisis and the ongoing struggle of being without sufficient resources. As a result, locum tenens recruiters have been responsible for filling gaps in medical care in remote regions. These physicians have the professional flexibility to travel and also control the scheduling of work intensity and commitment for brief periods of time. As a result, notwithstanding the fluidity of providers, underserved regions are capable of receiving necessary care.
Rural medicine affords a special sense of professional and personal importance for providers. Rural practitioners have the opportunity to develop long term relationships with patients and their families. They frequently are viewed as important community leaders serving multiple important roles. For example, it is not uncommon to be in the position of treating acquaintances, close friends and even family members. The role of being the town doctor comes with many hats and the unique opportunity to have private individualized relationships with a wide range of patients (Miller, 2011). In addition to a lower cost of living and slower pace of life, physicians report very positive doctor-patient relationships as a primary motivator to practice in a rural setting.
In conclusion, we have identified some of the critical challenges and opportunities associated with rural workforce development. For example, job satisfaction and job stability rather than workload and pay are factors that prevent professional burnout. A survey of hospitals in the US shows that richer benefits such as health insurance and vacation time are the most common incentives used to recruit physicians (Zen et. al., 2004).
In addition, hospitals that offer other benefits including flexible hours, tuition reimbursement and signing bonuses based on experience or length of commitment reinforce professional staff with the incentives of stability and continuity. Practitioners who are valued, offered interesting training opportunities and are satisfied with promotion remain the most dedicated and motivated individuals in the workforce.