In all his dreams about becoming a doctor, Ivan Becerra, MD, never imagined he’d lead a cesarean section delivery during just his second year of residency. Yet last August, that’s exactly what he was doing at Pecos County Memorial Hospital in Fort Stockton.
“It was exhilarating, and it was hair-raising,” the family physician said. “It was like, ‘This is on me now.’ I’m doing all the things I’ve seen other people do. But it’s also very exciting to know that I can do that now.”
Dr. Becerra is one of eight physicians participating in a rural training track Texas Tech University Health Sciences Center (TTUHSC) at the Permian Basin in Odessa (tma.tips/TechRTT) launched in 2014. The program is designed primarily to get physician trainees into rural areas, where Texas’ long-standing doctor shortage is most severe.
But the program also is designed to give young physicians like Dr. Becerra the experience most family doctors don’t get when they train at big-city hospitals, says Timothy Benton, MD, regional chairman and associate dean for clinical affairs at TTUHSC in Odessa.
“They’re the only ones there [in small towns],” said Dr. Benton, who oversees the rural training track. “Other physicians aren’t going out there. It’s family doctors who are providing rural care across the nation.”
The rural training track’s long-term goal is to identify and recruit physicians who want to settle in rural areas. Numerous studies have shown that physicians tend to set up practice near their residency site. Creating residencies in places like Fort Stockton, with about 8,500 people, is considered one of the best ways to get young physicians interested in rural practice and keep them there.
That’s also why Rolling Plains Memorial Hospital in Sweetwater, with a population of about 10,000, is part of Texas Tech’s rural training track. Though the residency costs the hospital about $85,000 a year, it’s probably the most effective way to recruit physicians to the area, says hospital administrator Donna Boatright.
Her hospital could use a headhunter to find experienced doctors or pay for a medical student’s tuition in exchange for later work, Ms. Boatright says. But those recruiting approaches are often just as expensive as a residency position, and they don’t create the kind of “trial marriage” arrangement of a residency, she says.
“It’s a great way for us to get to know each other and know if we’re going to be a match down the way,” Ms. Boatright said.
Rural medicine’s challenge
There are 39 rural residency programs across the United States, according to the RTT Cooperative, a group that encourages health profession education in rural areas. Texas Tech’s is one of three in Texas, along with similar programs at The University of Texas Health Science Center at Tyler and The University of Texas Medical Branch at Galveston.
Do rural training tracks create more rural physicians? In 2017, the Journal of General Internal Medicine published a survey of studies on efforts to recruit rural physicians. It found that these programs’ success rates range widely, from 30 percent to 65 percent.
The physician shortage in rural areas is part of a larger nationwide shortage. (See “A Deepening Shortage,” page 38.)
Texas physicians are not well distributed between urban and rural areas, and the state leads the country in rural hospital closures. (See “Coming Up Short,” page 37, and “Crisis in the Country,” November 2017 Texas Medicine, pages 55-59, www.texmed.org/CrisisInTheCountry.)
In mostly rural West Texas, the shortage of physicians is especially severe, says Charles Sponsel, DO, TTUHSC associate professor for family and community medicine.
“From the time I’ve been [at TTUHSC] in the early 1990s, our mission has been to go out and find physicians for rural areas,” said Dr. Sponsel, who helped found the school’s rural training track. “We’ve been trying, but it’s been hard to do.”
It’s also been difficult to secure funding for more rural residencies. In 2017, for instance, the Texas Medical Association supported House Bill 2996 by Rep. Trent Ashby (R-Lufkin), which would have established a small rural resident grant program, but the bill failed in the Texas Legislature.
Even with more financial help, recruiting rural physicians can be hard. Association of American Medical Colleges data says that less than 3.4 percent of U.S. physicians report interest in rural work. Most physicians train in areas where they have the support of large hospitals and plenty of medical specialists.
Rural physicians, by contrast, have to be ready to handle whatever medical problems their patients might bring, Dr. Sponsel says. Texas Tech’s rural residents are trained with that kind of career in mind.
“Our rural family practice residents learn to do colonoscopies, EGDs, central lines, and other procedures,” he said. “This is an advantage because family physicians normally are not qualified or allowed to perform these procedures in urban hospitals due to lack of experience or other factors. Even if they don’t end up in rural areas, our residents have more confidence when they start their practices.”
There are eight residents in Texas Tech’s rural training track. That will expand to 10 by July 2019.
Each resident spends his or her first year of residency in Odessa at Medical Center Health Systems, one of West Texas’ largest hospitals. Trainees do an intensive series of rotations in several specialties designed to get them ready for the wide variety of cases they’ll handle over the following two years, when they move out to small-town hospitals, Dr. Benton says.
By July 2020, the program’s residents will be spread among four rural hospitals: those in Fort Stockton and Sweetwater, along with Big Bend Regional Center at Alpine and Permian Regional Medical Center in Andrews.
The residents regularly make the drive back to Odessa to report on their progress. Most of the time, though, they live and work in the small towns they’ve been assigned to, so they quickly become immersed in community life. Since July, Dr. Becerra has been invited to a wedding, and he’s frequently welcomed into people’s homes.
Tanner Neuman, MD, a resident in Sweetwater, says his work as a physician also has brought him closer to people in town.
“You’re treating not just one patient but that patient’s family members and extended family,” he said. “Everyone kind of gets familiar with you. It’s a great feeling.”
Participating hospitals choose their own residents, and the hospitals are naturally looking for residents who are likely to stay and set up practice, Dr. Benton says. Research shows that physicians who grow up in small towns are most likely to set up a practice in small towns. Another big factor is the profession of the physician’s spouse. Many physicians are interested in rural work, but their husband or wife may work in a field like computer software, which requires employment in a big city, he says.
Physicians who want a Starbucks on every corner are going to be disappointed by small-town life, says Dr. Neuman. He enjoyed growing up in Fort Worth with its big-city amenities, but he also spent a lot of time in the small town of Naples because his father lived there. His wife is a nurse who grew up in Glen Rose, another small town.
“So it wasn’t all shock and awe when we moved here,” he said.
He has been struck most by the huge medical need in the area. Many patients are low-income and lack health insurance. Even those who don’t must weigh each visit to a physician against the expense of a long drive.
“They can’t afford to travel 40 miles to see a doctor and, in an area like Sweetwater, there’s under 10 primary providers,” Dr. Neuman said. “There’s a vast need for more primary care [physicians] to find their way out to these environments.”
Not every physician who goes through a rural training track like Texas Tech’s gets sold on rural medicine: Of the three graduates so far, one moved to the Seattle area, one will probably end up in a large or medium-size city, and the third is practicing rural medicine.
As for Dr. Neuman, he’s enjoying rural work. He and his wife recently had a baby girl and they feel a small town like Sweetwater is a good place to raise her.
“I’ve only been here since July, and I feel very confident so far that this is probably going to become home for me,” he said. “There’s opportunity for me to stay and make a big difference in the community.”
Tex Med. 2018;114(12):32-37
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