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Culture and Medicine
Physicians and rural America
PROVIDER SHORTAGES IN RURAL AMERICA
Many rural Americans have limited access to health care.
This problem stems from 2 characteristics of the health
care system: the many Americans without health care in-
surance and the tendency of health care professionals to
locate and practice in relatively affluent urban and subur-
ban areas.
The relative shortage of physicians in rural areas of the
United States is 1 of the few constants in any description
of the US medical care system. About 20% of the US
population—more than 50 million people—live in rural
areas, but only 9% of the nation’s physicians practice in
rural communities.
1
Crude comparisons of the physician-to-population ra-
tio in rural versus urban areas can be extremely misleading
and provide almost no information about whether short-
ages or surpluses exist in either location.
2
In 1995—the
latest year for which data are available—gaps existed be-
tween the supply of active physicians in counties of dif-
ferent size (figure 1). As can be seen in this figure, major
differences persist between the aggregate supply in urban
and rural areas, with the larger counties having many more
physicians per 100,000 population.
But this information obscures the fact that the physi-
cian supply has grown in rural areas in the past 20 years,
although the growth has not been uniform. The supply of
rural physicians has increased modestly in the past few
decades, with most of the increase in the larger rural com-
munities adjacent to metropolitan areas (figure 2). Rural
supply lags far behind the current urban supply of physi-
cians, but the urban supply of physicians is, in the opinion
of many, excessive.
Physician supply in rural areas is closely tied to the
specialty mix of American physicians. Specialty has a pow-
erful effect on physician location choice for each of the
major specialty groups (figure 3). Family physicians dis-
tribute themselves in proportion to the population in both
rural and urban locations and are the largest single source
of physicians in rural areas. All other specialties are much
more likely to settle in urban areas.
Given the expansion of the rural physician supply, it is
important to distinguish between rural areas that have
definite shortages of critical health professionals and those
that have fewer health professionals relative to oversup-
plied urban areas. Historically, the government has desig-
nated areas as seriously underserved based on the physi-
cian-to-population ratio within a specific health service
area. Populations with too few physicians have been
categorized as health professional shortage areas, thus
becoming eligible for a broad array of governmental
assistance.
Figure 1 Active physicians per 100,000 population by location, 1995. From AMA from BHPr ARF
data, 1997.
Douglas Diekema
Summary points
• There is a relative shortage of physicians in rural areas
of America
• The more highly specialized the physician, the less
likely he or she will settle in a rural area
• The preference of women for urban practice may pose
a problem for the future recruitment of rural
physicians
• Although managed care systems can recruit
physicians to rural areas, systems are growing slowly
in rural areas and their doctors may be of little use to
the working poor who have neither Medicaid nor
conventional health insurance
• Possible solutions to the problem of physician
shortages in rural areas include changing the medical
education system so that it trains more physicians
who choose rural practice, changing the
reimbursement strategies of Medicare and Medicaid,
and changing the existing federal and state programs
Roger A Rosenblatt
Department of Family
Medicine
University of
Washington
L Gary Hart
WWAMI Rural Health
Research Center
Box 354696
University of
Washington School of
Medicine
Seattle, WA 98195-4696
Correspondence to:
Dr Hart
gary_hart@fammed.
washington.edu
Competing interests:
None declared
West J Med
2000;173:348-351
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348 wjm Volume 173 November 2000
EFFECT OF SPECIALTY CHOICE AND DISTRIBUTION
Nothing affects the location decision of physicians more
than specialty. The more highly specialized the physician,
the less likely he or she will settle in a rural area. As a
consequence, the growth of specialization is a major con-
tributor to the geographic maldistribution of physicians.
Many of the shortages in communities with fewer than
10,000 residents could have been reduced or eliminated if
even a small fraction of subspecialists produced over the
past 15 years had chosen to become primary care physi-
cians in rural or underserved areas (T R Konrad: “Short-
ages of Physicians and Other Health Professionals in Rural
Areas: Background Paper Produced for COGME”; Cecil
G Sheps Center for Health Services Research, University
of North Carolina at Chapel Hill, unpublished, 1997).
The recently revived interest in family medicine and
the other generalist disciplines is a major factor in address-
ing rural geographic maldistribution. The decreasing pro-
portion of generalist physicians leveled off in the 1980s
(figure 4).
3
Despite recently increased interest in primary
care, the percentage in generalist disciplines has not yet
shown a substantial increase. An improvement in the bal-
ance of generalists and specialists is a necessary precondi-
tion for eliminating rural physician shortages.
EFFECT OF GENDER ON CHOICE OF
PRACTICE LOCATION
Starting a decade ago, the proportion of women attending
medical school increased rapidly. The number of female
physicians in the United States more than quadrupled
between 1970 and 1991 and has continued to rise.
4
Historically, rural medical care was almost exclusively
provided by male physicians. This was a product of the
paucity of women in medicine and the tendency of the
few female graduates to locate in urban areas. Male gen-
eralist physicians far outnumber their female counterparts
in rural areas across the United States. As the proportion
of women in medical schools has increased, there have
been concerns that the supply of rural physicians might
dwindle if women continue to settle almost exclusively in
urban areas and the largest rural cities.
Recent work suggests that the disparity between male
and female physicians may be growing less acute with
time.
5
The gap between male and female family physi-
cians has narrowed dramatically for more recent graduates
(figure 5). Still, even women in the most recent graduate
cohort are much less likely than their male counterparts to
locate in rural areas, and the disparity is greatest for the
smaller and more remote communities. The continuing
preference of women for urban practice—even though less
pronounced than in earlier years—may still pose a prob-
lem for the future recruitment of rural physicians.
INFLUENCE OF MANAGED CARE
Managed care is a major emerging influence on the delivery
of rural health care. Although it has become dominant in
many urban areas, its effect in rural areas is just beginning to
be felt. More than 80% of all rural counties were in the
service area of at least 1 health maintenance organization
(HMO) by the end of 1995, although the percentage of the
rural population enrolled in HMOs is estimated to be less
than 8%.
6
Managed care is not only a creature of the
private sector; nationally, about a tenth of rural Medicaid
Figure 2 Active physicians per 100,000 population by year and location, 1940 through 1995. From
AMA from BHPr ARF data, 1997.
Figure 3 Patient care physicians per 100,000 population by location and specialty, 1995. From
AMA from BHPr ARF data, 1997.
Douglas Diekema
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Culture and Medicine
Volume 173 November 2000 wjm 349
recipients are enrolled in Medicaid HMOs and prepaid
plans, and the number is increasing rapidly.
Managed care is a 2-edged sword, both with regard to
geographic maldistribution and rural medical underser-
vice. Managed care networks have the potential to provide
organizational vehicles for hiring and deploying physicians
in areas that could not support independent physicians on
their own.
But there are 2 potentially adverse effects of managed
care systems on rural health: the loss of local control of
health care systems and the reluctance of private managed
care systems to provide care to the uninsured. Most man-
aged care systems are sponsored by large metropolitan
organizations, and these entities may have little under-
standing of or empathy for isolated rural areas. The pres-
ence of physicians hired through vertically integrated sys-
tems may mean that the community has health
professionals, but they may be of little use to the working
poor who have neither Medicaid nor conventional health
insurance. The managed care industry is in rapid flux, and
the extent to which managed care will ultimately domi-
nate rural areas as it has dominated some urban ones is
difficult to predict.
POSSIBLE SOLUTIONS TO THE PROBLEM OF
INEQUITIES IN RURAL HEALTH
Educational initiatives
One of the most powerful ways to remedy problems of
rural geographic maldistribution is to change the medical
education system so that it selects, trains, and deploys
more health care workers who choose to practice in rural
areas. Much of the federal support incorporated within the
Title VII programs—the major federal vehicle for gener-
alist training—is based on the premise that this is an
achievable goal. Talley has discussed the 4 basic “truths”
about rural health
3
:
•Students with rural origins are more likely to train in
primary care and return to rural areas,
•Residents trained in rural areas are more likely to
choose to practice in rural areas,
•Family medicine is the key discipline of rural health
care, and
•Residents practice close to where they train.
To the extent that these relationships are accurate—and
evidence supports associations between these characteris-
tics and the decision to practice in rural areas—
modifications of the training milieu to incorporate these
factors make sense.
The advantage of this approach is that it takes opti-
mum advantage of free-market solutions to the problem of
geographic physician maldistribution. Rather than requir-
ing the establishment of federal or state delivery systems
that may be controversial, complex, and expensive, gradu-
ating residents gravitate to underserved areas to fill their
personal desires.
Although this type of intervention does not lend itself
to controlled experiments, ample evidence exists that such
an approach works. Publicly owned medical schools in
rural states, particularly those that see their mission as
training future family physicians, have high proportions of
their graduating classes ultimately practicing in rural areas.
By contrast, research-intensive private schools in metro-
politan areas with no commitment to family medicine
have virtually no rural graduates.
4
Changes in reimbursement strategies of
Medicare and Medicaid
A powerful mechanism to improve the flow of health
professionals to rural areas is the use of targeted incentives.
Central to this approach is the belief that physicians and
others act as rational economic beings. If some form of
economic inducement enhances the reimbursement for
rural services, then physicians are more likely to locate in
these areas. This approach has been used with some
success in Britain, Canada, and Australia, where a vari-
ety of bonuses increase reimbursement for selected rural
practitioners.
Figure 4 Percentage of primary care and non-primary care physicians for selected years, 1931
through 1996. From AMA from BHPr ARF data, 1997.
Figure 5 Male to female family or general physicians by graduation cohort, 1997. From Ellsbury
KE, Doescher MP, Hart LG. US medical schools and the rural family physician gender gap. Fam
Med 2000;32:331-337.
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Culture and Medicine
350 wjm Volume 173 November 2000
Changes in existing direct federal and
state programs
When educational interventions and economic incentives
fail to remedy geographic maldistribution, the major re-
course is the creation of programs that provide direct ser-
vices to underserved areas. There are numerous examples
of such programs, the largest of which are the community
health centers and the National Health Service Corps
(NHSC). There is no question that these 2 federal pro-
grams remain the preeminent safety net programs for rural
America. Studies by the Rural Health Research Centers in
Chapel Hill, NC, and Seattle demonstrate that about 1 in
4 of every new primary care physician entering a health
professional shortage area in the late 1980s was placed
there under NHSC auspices
7
and that 1 in 5 physicians
practicing independently in many of the smallest rural
communities was initially brought to those areas through
their service in the NHSC.
8
Given the realities of the current system, future efforts
should concentrate on improving the fit between need and
services, enhanced coordination—and reduced duplica-
tion—of services provided, better identification of stu-
dents to ultimately serve in the NHSC and state pro-
grams, and improved effectiveness and efficiency of
governmentally sponsored health care services, including
those of rural health clinics.
9
The wide variety of programs
available—and the natural variability in the way they are
organized and administered—leads to enormous com-
plexity in the provision of services. It is certainly worth the
effort to simplify programs and their administration and
to ensure that governmental resources follow human need,
not the administrative prowess of officials who excel at the
bureaucratic skills that can obtain these services for their
communities.
New technologies: possible effect
of telemedicine
Telemedicine is an emerging technology with enormous
potential for mitigating the effects of the geographic mal-
distribution of health professionals. Although telemedicine
has a legitimate, important, and growing role in rural
medicine,
10
the path to the future is uncertain. As pointed
out in the 2nd Invitational Consensus Conference on
Telemedicine and the National Information Infrastruc-
ture, multiple and significant obstacles exist that make the
current efforts uncoordinated, expensive, inaccessible, and
at times even illegal.
11
The current state of telemedicine could be character-
ized as creative but relatively unstructured, with a wide
variety of public and private sector experiments proceed-
ing simultaneously. Some applications, such as reading
electrocardiograms at a distance, have become common-
place. Others, such as dermatology consultations, are be-
ing performed in many different places but without stan-
dard protocols for transmission, interaction, evaluation, or
charging. And others, such as doing an appendectomy at
a distance, remain in the realm of science fiction, if just
barely. From the standpoint of geographic maldistribu-
tion, there are 3 key issues (see box).
CONCLUSIONS
Geographic maldistribution of health providers is 1 of the
most deep-seated characteristics of the American health
care system. Even though the 1990s have been marked by
rapid expansion in the absolute and relative number of
practicing physicians, substantial rural shortages have per-
sisted. Rural areas will continue to have structural barriers
that will require special programs to assist in the training,
deployment, and support of health professionals.
This article is adapted, with permission, from Ricketts III TC: Rural
Health in the United States. New York: Oxford University Press; 1999.
....................................................................................................
References
1 Bureau of Health Professions. Rural Health Professions Facts: Supply and
Distribution of Health Professions in Rural America. Rockville, MD:
Health Resources and Services Administration; 1992.
2 Center for the Evaluative Clinical Sciences, Dartmouth Medical School.
The Dartmouth Atlas of Health Care. Chicago: American Hospital
Publishing; 1996.
3 Talley RC. Graduate medical education and rural health care. Acad
Med 1990;65:522-525.
4 Rosenblatt RA, Whitcomb ME, Cullen TJ, Lishner DM, Hart LG.
Which medical schools produce rural physicians? JAMA
1992;268:1559-1565.
5 Doescher MP, Ellsbury KE, Hart LG. The distribution of rural female
generalist physicians in the United States. J Rural Health
2000;16:111-118.
6 Casey MM. Rural managed care. In: Ricketts TC III, ed. Rural Health
in the United States. New York: Oxford University Press; 1999:113-118.
7 Konrad TR. The Rural HPSA Physician Retention Study: Final Report for
Grant No. RO HS 06544-0 from Agency for Health Care Policy and
Research. Chapel Hill, NC: Cecil G Sheps Center for Health Services
Research, University of North Carolina; 1994.
8 Cullen TJ, Hart LG, Whitcomb ME, Lishner DM, Rosenblatt RA.
The National Health Service Corps: rural physician service and
retention. J Am Board Fam Pract 1997;10:272-279.
9Rural Health Clinics: Rising Program Expenditures Not Focused on
Improving Care in Isolated Areas. Washington, DC: General Accounting
Office; 1996. GAO/HEHS-97-24.
10 Balas EA, Jaffrey F, Kuperman GJ, et al. Electronic communication
with patients: evaluation of distance medicine technology. JAMA
1997;278:152-158.
11 Bashshur RL, Puskin D, Silva J. Telemedicine and the national
information infrastructure. Telemed J 1995;1:321-375.
Key factors in improving the delivery of
telemedicine to rural areas
•Resolution of the professional licensure regulations,
allowing physicians in metropolitan areas to make
their expertise available to remote rural areas, even
across state lines
•Clear protocols for a unified technologic infrastructure
to reduce costs and to allow rural providers to have
the option of communicating with multiple providers
of these distant services without being captives of any
single information provider
•Reasonable reimbursement by third-party payers for
providing medical services at a distance
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Culture and Medicine
Volume 173 November 2000 wjm 351
