Rural areas throughout the United States often have trouble recruiting and retaining physicians due to their low populations.
Opinions vary on whether Maryland has a true shortage of primary-care physicians of if they’re just not well-distributed; but the effect on residents of rural Maryland is the same – they may not find a doctor when they need one, Dr. Richard Colgan said.
Colgan is the co-founder of a University of Maryland School of Medicine program that’s trying to flip the script and get more medical students to choose primary care – particularly in rural areas – as their career focus.
This means paring students with primary care physicians in Western Maryland and the Eastern Shore – as well as in Baltimore City, which faces some of the same challenges – to expose them to the practice of family medicine, Colgan said.
Launched in 2012, the Primary Care Track is a collaborative effort between several departments of the medical school and just one way the medical community is responding to what officials see as an insufficient medical workforce serving rural Maryland.
New technology, tax incentives, partnerships between health systems and new efforts to train community members to be stewards of their neighbors’ health are also being used to address the problem statewide.
Thirteen of Maryland’s 24 counties appear to have an inadequate supply of primary care physicians. The largest shortfalls are in Somerset, Dorchester and Caroline counties, according to a 2014 study commissioned by the Maryland Health Care Commission.
A 2012 study from the American Medical Association found ranked Maryland fiftieth in the country for graduating medical students who go into primary care.
One reason for that may be that medical students tend to come from well-served, more affluent areas and aren’t as sensitive to the needs of underserved populations, Colgan said, explaining that the program is trying to fix that.
“We’re trying to buy face-time [for these students] in an underserved area,” Colgan said. He and his colleague believe that once students see the passion that family physicians have for treating their patients, they’ll decide to follow a similar path.
Medical students tend to have made up their minds about how they plan to spend their careers by the time they enter the residency stage of their education, so exposing them to rural health care early on is important, said Lara Wilson, executive director of the Maryland Rural Health Association.
Students in the Primary Care Track program spend time each month shadowing a primary-care physician for their first two years, including spending 80 hours working with those doctors in their first summer. The students also have a chance to work with the same doctors – volunteers known as preceptors – in their third and fourth year.
That training is coordinated through the Maryland Area Health Education Center (MAHEC) program, which is overseen by Colgan and has locations in Baltimore, Allegany County and Dorchester County.
While it’s too early to gauge how many graduates have gone on to stay and practice in these underserved areas, Colgan said one indication of success is that one-third of the medical school’s student body has joined the track, and the 2019 cohort was the largest yet with 64 students.
But this year’s crop of students is expected to be much smaller due to the increased cost of housing of students shadowing doctors at the Western Maryland and Eastern Shore centers.
Funding for those centers, which comes from the federal Health Resources and Services Administration, has remained flat for years but the expense of housing the students has risen, Colgan said.
Some relief may come from legislation passed earlier this year offering a tax credit to physicians and nurse practitioners who serve as uncompensated preceptors in underserved areas. The bill offers a credit of $1,000 per student, up to $10,000.
“It’s a great way to incentivize physicians to take on that role,” Wilson said of the tax credit, but said it would be helpful for similar incentives to encourage training other types of medical workers.
Providing residents with adequate health care takes more than just doctors; it also requires physician assistants, nurse practitioners and other support staff, she said.
Enter the community health workers, who are trained to help people in the area get the care they need – acting as a sort of liaison between residents and providers rather than a clinician.
These workers are “the next big thing” for improving health education in rural areas, Wilson said.
The Area Health Education Centers in Western Maryland and on the Eastern Shore have been training these workers for years, Colgan said.
While the state has no licensure or certification requirement for community health workers, the MAHEC program recently finalized comprehensive, uniform curriculum Colgan hopes can become a national model.
Connecting rural Marylanders with medical specialists is another challenge, one that Garrett Regional Medical Center in Garrett County is addressing by effectively sharing doctors with a hospital in West Virginia.
“It’s very difficult to recruit and maintain specialists here,” said Kendra Thayer, the hospital’s chief nursing officer and vice president of patient care services. But that can mean sending patients either to Morgantown or Cumberland for the care they need – each one an hour away in either direction, she said.
So about a year ago, the hospital entered into a clinical affiliation with West Virginia University Medicine to bring specialists such as a cardiologist and a nephrologist from that health system to Garrett Regional part time – usually one day per week or every two weeks, Thayer said.
Patients recovering from strokes can also see neurologists through telemedicine – essentially a live video chat between the patient, accompanied by Garrett Regional staff, and an off-site specialist, Thayer said.
Union Hospital in Cecil County has also had success with telemedicine, offering patients with some chronic illnesses such as diabetes or chronic obstructive pulmonary disease a way for nurses to monitor their health both quickly and remotely, said Anne Lara, the hospital’s senior vice president and chief innovation officer.
Since January 2015, the hospital has offered about 70 patients a free kit containing devices such as a scale, a pulse oximeter, a blood pressure cuff and a tablet computer – all of which communicate with each other wirelessly, Lara said.
Patients use the kit to take their own measurements from home each day, and nursing staff at the hospital can see that data through a secure web portal. Nurses can also ask questions about how patients are feeling or how they’ve slept, for example, and video conference with patients using the tablets, Lara said.
“It’s all very, very easy,” she said.
Since the program began, only two of those patients have been readmitted to the hospital within 30 days of being discharged – an important indicator of how well their chronic illnesses are being managed, Lara said.
The technology has been a boon to the two nurses who are the primary managers of the program, allowing them to amplify their abilities and reach more patients than they could otherwise.
“If each patient needed a home visit … we couldn’t do it,” Lara said.