- Welcome everyone, Wednesday Nite @ the Lab.
I'm Tom Zinnen.
I work here at the UW-Madison Biotechnology Center.
I also work for the Division of Extension, Wisconsin 4-H.
And on behalf of those folks and our other co-organizers,
PBS Wisconsin, the Wisconsin Alumni Association,
and the UW-Madison Science Alliance,
thanks again for coming to Wednesday Nite @ the Lab.
We do this every Wednesday night by Zoom, 50 times year.
Tonight it's my pleasure
to introduce to you Laura McDowell.
She was born in Hasting, Minnesota,
and went to high school in Storm Lake, Iowa.
Then she went to the University of Minnesota
for her undergraduate, where she majored in physiology.
She stayed on at the University of Minnesota
to go to medical school there.
And then in 2017, she came to UW-Madison
School of Medicine and Public Health
to be the first-ever resident
to go through the first in the nation
Rural Program in Obstetrics and Gynecology.
Tonight, she's gonna talk with us
about the importance of rural training in medicine.
Would you please join me in welcoming Laura McDowell
to Wednesday Nite @ the Lab?
- Thank you, Tom so much for that kind introduction.
I am so excited to be able to speak
with you all this evening
about the importance of rural medical training.
I have no financial disclosures, but certainly have benefited
from many different rural training experiences
in my medical experience,
both in medical school and in residency,
so I do have a bias towards them.
As learning objectives for our time here together,
my goal is that by the end of this talk,
that we will be able to first analyze
the pros and cons of rural practice,
be able to evaluate why a shortage
of rural OB/GYN providers exists within the United States,
and lastly, that we will be able to discover ways
to promote a solution to the rural physician shortage
through training track learning.
We will accomplish this today based off
of this general outlook, an outline for our time.
Throughout our time here, I will be interweaving my story
through answering the different learning objectives
with first focusing on background information
for rural living, followed by rural obstetrics,
the importance of rural medical exposure,
and lastly, concluding our time with next steps.
How I hope that we will be different
by our time here today.
So to start things off with my experience.
In the middle of my second grade year,
my family moved to a small northwest town
in Minnesota called Alvarado.
At the time, it had a population of 356 people
and was certainly a close-knit community.
It took a little bit of time
for my family to fully integrate into the community,
but as we were five hours away
from any of the rest of our extended family members,
the community members truly took us in as their own.
And I acquired many different grandparents, aunts
and uncles, and cousins through this experience.
It was through this time in Alvarado
that I was able to see my parents engage
in the community in a different way than how they had
in our distant suburb of the Twin Cities
in Hastings, Minnesota.
Here, they were a part of various community organizations
such as Lions, and both of them participated
in an emergency response team, where they responded
to various emergencies throughout the area
and were a vital part to the community in that regard.
It certainly brought them a lot of fulfillment
and satisfaction being a part of the community,
and I know that community members
certainly respected them highly.
Moving into high school,
our family actually moved down to northwest Iowa
to a town called Storm Lake,
which is a town of about 10,000 mixed population
in the northwest corner of Iowa.
In Storm Lake, they have Buena Vista Regional Medical Center,
which is a critical access hospital
for the County of Buena Vista.
It was here and in high school
that I was discerning what my future would hold
in terms of career paths.
I knew that medicine was a likely potential for me,
and was trying to decide whether going on
to being a nurse, a physician, or even a forensic pathologist
would be what I would want to do.
I was really interested in CSI as a kid.
So through this experience with the hospital,
I was able to shadow many different
family practice physicians
and also receiving care from them at points in time.
And through those experiences, I chose to pursue medical school
as my future goals moving forward.
Arguably, one of the most impactful experiences
of my formative years was when I was given
the opportunity to travel to Tanzania, Africa
for a month in the summer between my junior
and senior years of high school.
During this experience, I was able to engage
with several different communities
and organizations in Tanzania.
Some of the highlighted experiences include time spent
in a girls' secondary school outside of Chimala, Tanzania.
I was also able to tour a rural hospital
in southwest Tanzania,
in addition to being able to take care of some kids
that were affected by HIV, either themselves
or that their parents had died from the virus.
It was through this impactful experience
that I felt charged to actually pursue global medicine
initially in my career path.
It wasn't until reflecting upon my time
in Tanzania a few years in the future
that I had determined that, you know,
certainly there is a need abroad
and underserved populations abound there,
but there is a need here in the United States as well.
And some of the communities
that I had actually been a part of
were considered a great part of the need in rural areas.
And I felt called to be a part of that solution,
to return to these rural communities
that had so gratefully
and kindly taken me and my family in.
So we certainly will be talking a lot
about rural here today.
So I thought that it would be helpful
for us to give a definition of what is rural?
So if you were to look in Merriam-Webster's dictionary
and find the definition of rural,
it would come up with "of or pertaining
to country, country people, or life or agriculture."
In a research aspect of rural,
there are many varied ways to define rural.
If you looked at the Census Bureau's definition,
they essentially define rural as a negative of urban,
where they describe urbanized areas
as consisting of cities with populations
of 50,000 people or more,
and urbanized clusters consisting of 2,500
to just under 50,000 population.
Essentially, populations that aren't included
in the urbanized area or urbanized clusters are rural,
consisting of their population,
their housing, and adjacent territory.
If you were to look at another different research way
of defining rural and in terms
of the core-based statistical areas
shown here in this figure, they define rural based off
of metropolitan and micropolitan statistical areas,
with metropolitan statistical areas having the largest city
within the county having at least 50,000 people or more.
And they also associate their community ties,
both financial, social, economic,
as a part of their metropolitan status.
In regards to micropolitan statistical areas,
they are defined similarly to metropolitan.
However, their largest city size within the county
consists of a population of between 10,000 to just
under 50,000 with its associated community ties as well.
Another way to define rural in the research realm
is using the National Center for Health Statistics
2013 Urban Rural Classification Scheme of Counties.
Here, they break down every U.S. county
into six different subcategories,
with metropolitan counties consisting
of having the largest city, at least 50,000 people
in population, ranging up to millions in population,
with the definitions used including entirety of population
within the county and metro-adjacent status.
In terms of non-metropolitan or what we will consider
to be rural for the remainder of this talk,
those counties consist of micropolitan
and noncore counties,
where micropolitan counties have their largest city
consisting of population greater than 10,000
to just under 50,000 people.
Whereas noncore counties
have their most populous city consisting
of less than 10,000 people in population.
So with this in mind,
certainly not all rural areas are created equally.
And as you can see here in this heat map,
there are varying population densities
within rural areas, with the most dense rural populations
being closest to urbanized centers,
as seen here with having the darker brown
consisting of more dense rural areas.
Additional rural statistics include
from the 2010 Census Bureau
that 60 million people in the United States
at that point in time lived in rural areas,
and they consisted of 19.3% of the population.
Additionally, from this figure shown here,
you can see that there are varying densities
and percentages of rural residents within each state,
with Maine actually having the highest percentage
of rural residents at 61.6%.
Now that certainly was a surprise to me,
I don't know about the rest of you.
Ongoing statistics include that the rural landmass
within the United States actually consists of 97%
of the landmass in America, which is very surprising.
But I think the converse is even more surprising,
that 80% of the United States population lives
within 3% of the United States landmass.
Now, some of you astute people might be thinking,
"Well, gosh, they just came out
"with some updated 2020 census data
at the end of April, why isn't that data included?"
So by the time of this filming of this talk,
they had not published any further breakdown
of urban and rural statistics.
So those are still to come
and something that we can all look up together.
This figure shows the National Center for Health Statistics
2013 Urban Rural Classification Scheme of Counties
as broken down for all six categories.
Again, as a refresher, we will be focusing on rural,
consisting of the micropolitan and noncore counties,
shown here in the two tones of green.
Other interesting statistics to note
is that 28 million of the 60 million rural residents
consist of reproductive-age women.
And these 28 million women are composed of 35%
of the entire U.S. reproductive-age population.
So these are statistics for us
to keep in mind for later on in the talk.
So not only are geographic challenges an issue
that rural Americans face, but according
to the Centers for Disease Control and Prevention,
they published this press release,
noting that rural Americans are at a higher risk
of dying from the five leading causes of death,
which include heart disease, cancer, unintentional injuries,
chronic lower respiratory disease, and stroke.
Not only are rural Americans at increased risk
of dying from these five leading causes of death,
but they are noted to be sicker
and older than their urban counterparts.
They have higher rates of smoking,
high blood pressure, and obesity.
And when they do have leisure time,
they are less likely to spend it in an active manner.
When rural Americans are out driving,
they're also less likely to wear seat belts,
predisposing them to motor vehicle accidents.
Rural Americans also have a higher rate of poverty,
they have less access to healthcare,
and are less likely to have health insurance.
In fact, according to the Kaiser Family Foundation,
24% of the non-elderly rural population
utilize Medicaid services for their primary payer.
Now, it is known that Medicaid reimbursement
is actually less than what private insurance pays,
but I think it's helpful for us to actually have
the breakdown of these numbers.
So it is known that Medicaid pays on average 87 cents
on the actual dollar spent for cost of care.
So hospitals that primarily are taking patients
that have Medicaid insurance are losing money
for the care that is provided to these individuals.
In regards to comparing reimbursement rates
from private insurance to Medicaid,
private insurance is known to reimburse double
what Medicaid does for in-hospital inpatient services.
And on the outpatient side of things,
private insurers are known to pay
about two to two and a half times more
than what Medicaid reimburses for those same services.
So hospitals that are providing majority of their care
to individuals with Medicaid are certainly at a burden,
as they're operating at a financial deficit.
Next, we'll focus our time on our first learning objective,
which is analyzing the pros and cons of rural practice.
Certainly, there is individual variation
between what is considered a pro
and what is considered a con of rural practice,
but we'll break those down in just a little bit here.
So according to the American Association
of Medical Colleges,
several physicians have noted varying reasons
of why they would not choose to practice in a rural setting,
including that there's an increased call burden
for physicians that practice in a rural area,
as they typically have less partners
to share the call requirements for their job.
Additionally, rural physicians are known
to be on average about 51 and a half years old,
and therefore nearing the age of retirement.
So if there are concerns for retirement
and call burden and recruitment of new physicians,
this can further worsen the issue of call
for the remaining rural doctors.
If the physician has a working spouse,
sometimes it can be challenging to find meaningful work
for that spouse in a rural setting.
If they have children, there's a concern
of having decreased structured learning opportunities
for their children, especially in the high school setting
as some rural areas do not offer advanced placement
or PSEO classes.
In regards to the rising medical tuition and debt concerns
in regards to reimbursement for physicians,
this is increasingly becoming a concern
for some medical students and residents,
and the feasibility of actually being able
to practice rural medicine in the future
and be able to get out of debt.
And lastly, there is this generalized culture
within medicine that there is special significance placed
on those individuals that choose
to specialize and subspecialize,
causing some medical students to potentially think a career
in family medicine or general practice
as not being advantageous enough for them.
So looking into some of the literature
about one of these challenges of rural practice,
I wanted to dive a little bit deeper
into the concerns of medical tuition costs and debt.
In 1970, the government noted
that this could be a potential problem
for individuals choosing to practice
in a rural or underserved setting,
and so created the National Health Service Corps
Loan Repayment Program in 1970.
This program primarily relied off
of discretionary appropriations prior to the passage
of the Affordable Care Act in 2010,
which actually designated funds
for this program specifically, allowing the program
to become more stable in terms of paying tuition
and stipends for these individuals.
So the National Health Service Corps was actually created
for healthcare professionals to receive funds to pay
for their medical schooling or healthcare schooling
in exchange for a predetermined number of years of service
in a rural or underserved area
that was designated based off of a number system,
with having more destitute or resource poor,
underserved, and rural areas
having a higher number on the scale.
Research behind the National Health Service Corps
Loan Repayment Program shows that having
a National Health Service Corps physician
in an underserved area does attract on average,
an extra two non-National Health Service Corps physicians
to the area; however, despite this additional recruitment,
it does not result in the area
losing its underserved designation.
Therefore showing that there are other issues afoot
that are not just related to primarily physician shortage.
Moving into some of the advantages of rural practice
that many rural practitioners have noted
as a reason for why to practice rural medicine
is that they enjoy living in a small town in a social sense,
having that sense of belonging
and being able to be a community leader
in the community that they care for.
Additionally, practicing in a rural setting allows
for clinical autonomy and being able to practice
at the top of the physician scope and training.
Looking into some research
into physician satisfaction with rural practice,
the study pictured here on the left by Pathman et al.
demonstrated that the greatest satisfaction
for physicians practicing in rural areas
comes from the patient-physician relationship.
And also, that this relationship
gives them much fulfillment in terms of responding
to a need in this underserved community.
They also note that clinical autonomy is something
that they hold professionally important to them,
and then they just generally enjoy living
in a small town setting.
Now, the study on the right by Cutchin
reported physician retention in addition
to how they integrate into the community.
And he noted that there are many different factors
with the physician themselves
and the certain, you know, physical environment
of the community that affect integration.
I think most importantly, what he points out in this paper
is that integration and retention actually start
from the very initial recruitment.
So when that physician is coming into a rural community,
they are trying to see if they can envision themselves
within that rural community.
And so, it's important even from the get-go,
when you have a learner in a rural community
to try to welcome them in,
to give them a positive experience about rural medicine.
So with this understanding of the background
of rural healthcare and its members,
in addition to different physician factors
of why people would want to practice rural medicine,
I'd like to integrate my experience back
into our time here together.
So growing up, I did live in
at least two smaller Midwest communities
and wanted to experience what the big city life would be like.
So in pursuing my undergraduate studies,
I decided to attend the University of Minnesota
in the Twin Cities.
I certainly received a great education from this university
and I would not have traded that experience for anything.
But during my time there, despite being involved
in many small groups, I still felt isolated from community
in a way that I hadn't felt before, growing up.
And I came to realize that I truly craved
that connectedness in rural communities
that I just wasn't experiencing in the city.
So fortunately for me, when I was pursuing medical school,
I was actually selected to go
to the University of Minnesota in the Duluth campus,
which has a special emphasis on training rural physicians
and physicians that are interested
in Native American health.
Through my first two years
of lecture-based studies in Duluth,
they also provided all of the medical students
an opportunity to go out to different rural communities
in both Wisconsin and Minnesota for us to spend time
with a rural, a family practice doctor,
understanding what practice life is like
for these rural physicians.
It was through this time that I was able
to apply what I learned in medical school
in an actual clinic setting.
Seeing patients, obtaining their histories,
performing a physical exam,
generating different differential diagnoses,
and attempting to come up with plans.
I certainly benefited from this experience
from a medical aspect, but from a social
and interpersonal aspect, I felt great joy
in caring for community members again,
and was hooked on this experience.
So through my time in the Rural Medical Scholars Program,
I knew that I wanted to pursue rural medicine
as my future, in my future career.
In my third year of medical school,
all of the students were given an opportunity
to either pursue our further clinical studies
in the Twin Cities or to participate
in a longitudinal integrated clerkship,
called the Rural Physician Associate Program or RPAP.
Due to my desire to practice in a rural setting,
I chose to participate in RPAP
and was selected to have my nine-month experience
in Hibbing, Minnesota, where I was able to work
with several different family practice, general surgeons,
pediatrics, and obstetrics and gynecology physicians.
Through these experiences,
I was able to see their patients in clinic
and follow them throughout their care process,
either seeing them again in clinic,
going to the operating room, or my most favorite,
getting to participate in their labor
and delivery experience.
Through this kind of longitudinal
and continuity of care,
I was hooked on that kind of patient-physician relationship
and knew that I wanted to continue that
in my further practice life.
And so through this experience,
I chose to pursue a career in obstetrics and gynecology.
So moving on to our second learning objective for today,
my hope is that we will be able to evaluate why a shortage
of rural OB/GYN providers exists in the United States.
In 2018, the American College of Obstetrics and Gynecology,
which is the governing body of all OB/GYNs,
put forth this committee opinion entitled
Health Disparities in Rural Women,
that showed that only 6.4%
of the OB/GYN workforce worked in rural locations.
Now, if you remember from back in earlier on in the talk,
35% of reproductive-age women
actually live in these rural areas.
So this is certainly a discrepancy
in terms of population,
well, physicians caring for that population.
In addition, from the Department of Health and Human Services,
they published this policy brief in May of 2020,
where they had noted that currently,
there's a shortage of 9,000 OB/GYN providers
that exist at this time
and is only anticipated to be getting worse,
projected to have a 22,000 OB/GYN physician deficit
by the year 2050.
What is even more staggering is that 50%
of the counties within the United States
actually do not have an OB/GYN provider.
And due to this shortage, it causes
about 10 million women to need to travel long distances
to receive basic routine prenatal care.
So if a woman were to have additional complications
in her pregnancy that required more frequent visits,
this becomes even more of a burden, especially for those
that are challenged with transportation
and other issues in their social lives.
So how do we fare here in Wisconsin?
So out of the 72 counties
that make up the State of Wisconsin,
46 of those counties are considered rural,
which again are the micropolitan and noncore counties,
shown here in the two tones of green.
Out of the counties within Wisconsin, there are 20 counties
that actually do not have an OB/GYN provider.
And 19 of those counties are considered rural,
two of them micropolitan
and 17 of those being noncore counties.
So lastly, I would like for us to focus our time
on discovering ways to promote solutions
to the rural physician shortage through training track learning,
which is our final objective for today.
According to the Centers for Medicaid
and Medicare Services and the Rural Report put forth
by the American Hospital Association,
there were four overarching reasons
for why different rural obstetric units
were closing their doors.
And they included issues regarding
the low obstetric volume, low reimbursement,
having a lack of skilled providers,
and the expense of keeping those providers trained
as being four overarching areas
that were needing to be addressed.
So since the medical community can actually do something
about these latter three options,
I would like to focus our time on these latter three reasons
for why OB units are closing in rural areas.
First off, with low reimbursement,
we discussed earlier
that Medicaid actually pays only 87 cents
on the actual dollar of costs provided
for patients, therefore causing hospitals
to operate at a financial deficit.
In addition, it's helpful to know that actually 51%
of rural deliveries are funded by Medicaid.
So this is affecting many, many rural hospitals
all across the nation.
In terms of, you know, this issue being known,
it's well-known in the scientific realm,
but I wanted to focus a little bit more
on what the general population knowledge is
of this health crisis.
This magazine article from Time magazine,
published back in November of 2020,
is actually a magazine clipping I received
from my aunt this past fall regarding the concerns
of Medicaid expansion or lack thereof
and the association of rural hospital closures.
As you can see here in this bar graph
from the study period of 2013 to 2017,
rural hospitals that did not have Medicaid expansion
within their states were more susceptible
to having their rural OB units close.
You can see here that Wisconsin is highlighted
as one of those states that has not expanded Medicaid.
Fortunately for Wisconsin, at least
at the time of this published article,
there were only one...
There was only one OB unit that had closed its doors
as of 2017 at that point.
However, according to the Wisconsin State Journal ,
this article published back in 2019,
they had reported that there were 11 rural hospitals
that had closed their doors in the preceding decade,
with the most recent closures occurring in 2017
in Grantsburg and Ripon.
They also noted that there were 35 hospitals
within Wisconsin that were at risk
of closing their obstetric units within the next upcoming years.
And they reported that there were five hospitals
that were going to be closing their doors,
but they hadn't given an exact closing date.
So just by the time of that published article,
there weren't a significant number of OB hospital closures,
but as time has gone on,
certainly there are ongoing effects
of not expanding Medicaid
and primarily affecting these rural hospitals
that are struggling to keep their doors open.
The figures shown here on this slide
are from a article published by Hung et al.
that describes access to obstetric services declining
over the last decades.
They show here highlighted within the state of Wisconsin
in the dark blue counties that those
are the counties that actually lost full obstetric services
for the entire county over this study period.
The counties that are considered rural
that did not have obstetric services
throughout this entire study population
are shown in medium blue, whereas the rural counties
that had ongoing OB services are shown in light blue.
In Wisconsin currently, we actually still do not have
Medicaid expanded for the entire state.
In regards to having a lack of skilled providers
as a reason for OB unit closures,
certainly this is an area of great concern,
and there are so many articles
out on the internet about personal stories
of women that have had their OB units close,
and what that has caused them to do.
Highlighted from the video
that is depicted here on the right
is a woman's story of being in active labor
in the Arrowhead of Minnesota.
She had to drive an hour and a half
to the nearest OB unit to be able to deliver her baby.
However, unfortunately she was in the active throes of labor
and was not able to make it to that OB unit,
and so had to deliver at a hospital
that no longer provided OB services.
So they were not equipped to take care of her
and her newborn baby.
In terms of ways that we as a medical community
and a community at large can help provide skilled providers
to these rural areas is by allowing exposure
for rural training in medical school
and residency as a potential solution.
Fortunately in 2017, the University of Wisconsin-Madison
OB/GYN department
created the first-ever rural OB/GYN training track
in the nation.
Through this training track,
residents that participate in it,
which include one resident per year,
is that six months of their four years in residency
are spent in four different rural communities pictured here.
We have gone to Portage, Monroe, Waupun,
and Baldwin for our time here.
And this consists of about 12.5% of our time in residency.
Of note, two of the sites
actually have solo practitioners,
meaning that they are the only OB/GYN on call
for their entire service and hospital,
and sometimes even county or two,
whereas the two other sites have two
or four providers respectively.
So it allows the resident to get an understanding
of what it is like to live and practice in a rural area
as being a solo provider or being a partner
within a practice that is certainly different
than an academic center.
In regards to the expense of maintaining provider training
as the final area of issue with rural OB unit closures,
I wanted to focus on two main questions I had about this.
How much does it actually cost to keep a provider trained
in obstetric emergencies specifically?
And is it actually effective to perform this training?
So looking at the article by Yau et al.,
they broke down costs of providing simulation training
for obstetric emergencies into startup costs
and variable costs, which are considered
to be annual and recurring costs.
They noted that overall,
the total cost was about $200,000
to provide this simulation training,
and the majority of that cost came
from releasing their attendees and trainers
to go to these simulation sessions.
In regards to cost-effectiveness,
this article published by Van de Ven et al.
showed that certainly doing simulation training
is cost-effective, but only
when it is repeated in repetition,
and that repetition at least needs to be completed once.
So you complete the training
and then you complete another training
further down the line.
So hopefully so far, I have been able to talk
with you all about the importance of adding providers
to the rural workforce, not only in OB/GYN
but throughout all of the specialties within medicine.
There is quite a bit of evidence that exposure
to rural medicine is one of the ways
that individuals decide to pursue medicine.
One of my rural preceptors actually grew up
in a major Midwestern city and ended up practicing
in that major Midwestern city following residency.
It wasn't until later on in his career that he made a change
and decided to practice in a rural setting.
He told me during one of our times together,
one of our months together, that he wishes
that he would have known about rural practice
from the get-go because he would have participated
and been a rural physician from graduating residency.
So I think that that further highlights
the importance of providing that exposure,
especially to people that don't come from a rural background,
as not all of us have that opportunity.
In addition to providing that much needed rural exposure,
I think the other issue is that we need to do better
as a medical society of recruiting individuals
that are going to be more apt to stay in rural practice.
And evidence has shown that that comes
from people that are from a rural background.
Unfortunately, according to Health Affairs,
an article published regarding
the 2017 Medical School matriculating class
demonstrated that 28% of those medical school matriculants
had actually decreased in percentage of rural background.
So rural medical school matriculants
only accounted for less than 5%
of the actual matriculated class of 2017.
And if you were from a minority and rural background,
you accounted for less than 0.05%
of the matriculating class.
So with this in mind, I'd like to transition back
into my time with rural medicine.
So certainly after completing medical school,
my hope and dream was to pursue rural medicine as an OB/GYN.
And much to my surprise and delight,
I was selected to be one of the residents
for the rural training track here
at the University of Wisconsin-Madison.
I was so overjoyed the day
that I opened my match day letter
with overwhelming feelings of happiness and relief.
I had really, really wanted to come here so, so badly.
And certainly through my time here,
it has impressed me beyond my wildest imagination.
I have learned so much through this program
by having the dichotomy of learning and practicing
in a high acuity, large volume academic center,
and comparing that with what rural practice is like.
I like to term it the rural reality.
'Cause certainly there are vast differences
in how you practice medicine in an academic institution
and in a rural institution.
And it was helpful for me to see how people did that
and how I was going to potentially
integrate my knowledge
and experience into my future rural practice.
So this educational experience has been hands down,
one of the most beneficial to me in my entire education.
So I have alluded certainly to some qualities
that are found in different rural physicians,
but this article published by Robert Tate
further emphasizes some other qualities
that are shown in rural providers,
that being male gender, having lived in a rural location,
or attended a rural high school.
In addition, having had rural training
in either medical school or residency
were associated with having rural providers
stay practicing in a rural area.
This systematic review published in 2017
further breaks down the different potential factors
for rural retention and their degree of importance.
As you can see here, one of the highest degrees
of importance is having a rural background.
So it is important for us to be recruiting individuals
that are from rural backgrounds to have them go back
and serve their rural communities.
However, for individuals that don't have
that same opportunity to be from a rural background,
having them have exposure to rural training
in medical school and residency was shown
to be a moderate degree of importance,
and certainly is something that the medical community can do
and would be important for us to continue that.
From the systematic review, it showed
that physicians that had graduated
from a rural training track were found
to be 44% likely to stay in that rural location
or practice in a rural area,
which is certainly better than 0% having not gone
through a training track experience like that.
So now some of you are probably with me and saying,
"Okay, yes, I understand how this is important,
"having rural exposure to get rural providers
into areas, I get that."
But for my experience,
in my interview trail for residency,
I went around to different Midwest towns
and to see where I wanted to pursue residency.
And one of those interviewers actually told me
that, you know, having rural exposure
and rural practice was not gonna be important.
I was told that only good things were
to be learned from the academic center
and that I wouldn't learn anything
from being out in a rural community,
so that that be a waste of my time.
And I think contrary to what the evidence says,
that, you know, this person's statement was incorrect.
We know that having exposure to medical training,
both in medical school and residency,
is one of the ways for us to address
this rural physician shortage.
Specifically, in regards to medical schools,
ways that we can be better include that only 21%
of medical schools actually provide
that much-needed exposure to rural training
and practice in medical schools.
And there are only 8% of medical schools
that actually express a commitment
to providing rural physicians in the future.
So these are areas of improvement for medical school.
In regards to residency training, as of 2016,
there were 99 family medicine rural training tracks,
there were 11 internal medicine rural training tracks,
and 11 general surgery training tracks.
And if we had added on 2017,
there would be one OB/GYN rural training track.
And I know that this has been expressed wholeheartedly
by the University of Wisconsin-Madison
OB/GYN Department,
that we hope to not be the only one in the nation.
We want to have many more OB/GYN training tracks
across the country to address this
rural physician shortage, especially for OB/GYN.
So hearkening back to these four reasons
for obstetric unit closure
with specific emphasis placed on these latter three,
I wanted to move into next steps of how I hope
that we can be different from our time here today.
In regards to having a lack of skilled providers
as a reason for the rural physician shortage,
as a medical community, we need to increase the number
of rural medical training exposure,
both in medical school and residency
throughout the United States.
And that is something that can be done
on both a medical school and a resident level.
In regards to the expense of maintaining provider training,
it is important for us to establish relationships
between the academic centers and rural hospitals
in order to share the burden of simulation training,
but also to exchange knowledge
and to have that working functional relationship,
as there is much cross-communication
between urban and rural hospitals and clinics.
So to wrap up our time here today,
we will be going through our learning objectives.
And so first, I hope that through our time here today,
that we've been able to analyze
the pros and cons of rural practice,
certainly understanding that different individuals
view a pro and a con differently.
In terms of challenges of rural practice,
call burden, concerns around a working spouse
and educational opportunities for children,
the issues around medical debt,
and valuation of specialization and subspecialization
in medicine have all been listed
as challenges for rural practice pursuits.
In regards to advantages of rural practice,
living in a small town in a social sense,
having a sense of belonging, being a community leader,
and having clinical autonomy
and practicing your full scope of training
have all been listed as advantages
for many physicians in these rural areas.
In regards to our second learning objective,
where we were evaluating why a shortage
of OB/GYN providers exists in the United States.
I hope that we have been able to discuss issues
regarding a lack of resources for care and reimbursement
for both hospitals and physicians
as one of the reasons for the shortage,
specifically that having a lack of exposure
to rural training and experience is one of the ways
that the medical community can certainly address this issue.
And in addition, knowing that this lack of exposure
and lack of skilled providers is one of the reasons
why these obstetric units are closing their doors.
In terms of retaining physicians,
this is another area that communities need to look at
in terms of keeping the rural physicians
that they have currently and recruiting those
to come and join their communities.
Lastly, I hope that we have been able
to discover ways to promote solutions
to the rural physician shortage through training track learning.
Providing that much needed exposure
to both medical students and residents
is one of those avenues for reaching this objective.
And then to help different hospitals
actually maintain their ability
to keep their obstetric units open
by creating a collaboration
between rural and urban hospitals in regards
to simulation training and knowledge exchange.
Last, but certainly not least,
I would like to think so many people
and especially the people that are listed here.
Dr. Jacques has been my mentor
over these last four years in residency here in Madison.
She is an outstanding provider and both clinically
and personally, I have learned so much from her.
I am grateful for all that she has provided me
in terms of knowledge of what medicine is like
outside of the hospital,
and certainly she was a huge part
of creating this presentation that you have seen today,
so thank you so much to her.
To Doctors Rice, Hartenbach, and Spencer
for having the vision to see the need
for this rural OB/GYN training track,
I will be forever indebted to you all.
And for having that vision to keep it moving forward
and expanding across the country,
for being collaborative mentors
for other residencies across the country.
I am so thankful for all of the hard work
and dedication that you have put in to make this a reality,
especially for me, but hopefully for other people in the future.
To the OB/GYN department, faculty, staff,
I am grateful to you all for all that you have taught me
over these past four years, clinically, interpersonally,
and you all have truly shaped me
into the young physician that I am today.
To the rural training site physicians and staff,
I am so thankful and appreciative
of your warm welcome
to me to your different communities,
and for allowing me to take care of your community members.
That has been one of the most life-giving experiences
of residency for me, and I am so thankful
for your kindness in that way.
To my current PGY4 class, I would not have been able
to make it through residency without all of you,
so thank you for all of the support
and listening ears that you have provided.
To residents past and present, I am grateful to you all
for helping me make it through residency.
It's a pretty grueling experience
and you've definitely helped pick me up by my bootstraps
when times were really tough, so thank you.
Ah, to my parents, family and friends,
oh, I would definitely not be here today
without your support and guidance.
Thank you so much for supporting me throughout,
especially these last eight years of medical training.
I would not have been able to make it through
without your support and encouragement,
especially to my parents who have helped me continue
to have the vision of what I initially sought out
medicine for in the first place when I lost that vision.
I am so grateful to you all in so many ways.
And a special thank you
to all of you listening to this talk today.
I am so grateful that you have taken the time to listen
and absorb the different reasons
of why medical training is important.
And I hope that it has charged you to think
about different ways that you can advocate
for addressing the rural physician shortage
in the future.
Thank you, and have a wonderful evening.