University of Wisconsin–Madison ⋅ Medical College of Wisconsin
WMJ

Addressing Health Disparities Through Rural Training

Jillian Landeck, MD; Ryan J. Spencer, MD, MS; Robert N. Golden, MD

WMJ. 2023;122(2):155-156.

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THE CHALLENGE

Approximately 1.5 million Wisconsinites, or 25% of our state’s population, live in rural areas, yet only 11% of physicians practice in rural Wisconsin.1 Rural communities comprise an important part of Wisconsin’s culture, history, and economy. However, due to social inequities and decreased access to health care, individuals who live in rural Wisconsin disproportionately experience negative health outcomes, leading to higher overall rates of morbidity and mortality. According to analyses from the Wisconsin Office of Rural Health and the Wisconsin Department of Health Services (DHS), people who live in rural areas have higher rates of many chronic diseases, including coronary heart disease and strokes. Life expectancy is 0.8 years lower for men and 0.5 years lower for women in rural Wisconsin. Access to primary care physicians, dentists, and mental health providers is significantly lower, and rates of uninsured children and adults are higher.1-3 Limited access to affordable housing, transportation, employment opportunities, telehealth, and broadband internet service disproportionately impacts individuals in rural Wisconsin and contributes to these negative health outcomes.

A lack of available clinicians is a significant driver of limited access to health care. The rural physician shortage is projected to grow as the need for a larger physician workforce expands due to the aging of the population and as current rural physicians retire. A recent study found that 12 (16%) of Wisconsin’s 76 rural hospitals are vulnerable to closure.4 Additionally, one-third of rural Wisconsin counties do not provide birthing services, and the number of rural hospitals that provide delivery services has declined 24% since 2009.5 Maintaining a sustainable physician workforce in rural Wisconsin is a critical element in addressing the disparities of health care access in rural Wisconsin.

THE WISCONSIN SOLUTION

The Wisconsin Idea permeates all we do — including our efforts to address the rural health care crisis in our state. The University of Wisconsin School of Medicine and Public Health (SMPH) has a long tradition of supporting residency programs that train outstanding physicians to serve rural Wisconsin. Founded in 1996, the UW Baraboo Family Medicine Rural Training Track (RTT) supports two residents per year and was the first RTT in Wisconsin. It provides a longitudinal, integrated curriculum with strong procedural training and unique opportunities that include electives in addiction medicine and tribal health. The program has a strong record of placing family medicine physicians in rural practice.

Building on the Baraboo program’s legacy, the SMPH has expanded rural training programs in recent years. In 2017, the Department of Family Medicine and Community Health (DFMCH) created the Family Medicine Rural Health Equity Track, which adds two residency slots per year and includes six months of rural rotations, along with unique experiences in leadership, community health, and advocacy for residents who intend to enter rural practice. In 2019, the school added a Rural Pathway option to its Family Medicine Residency Program. The DFMCH also provides support to statewide academic partner programs, including residencies in Eau Claire, La Crosse, and Wausau, as well as the Lakeland RTT in Barron County. Starting in July 2023, the DFMCH will provide Accreditation Council for Graduate Medical Education sponsorship and support to the Monroe Hospital RTT.

Many members of the SMPH community have recognized the critical need for a broad spectrum of physicians in rural areas. The school has become a recognized national leader in its support of rural training across multiple specialties. In 2016, the Department of Surgery launched its rural residency track, which places one general surgery resident each year into rural areas of Wisconsin for 12 months of training. In 2017, the Department of Obstetrics and Gynecology began the nation’s first rural track in this field; trainees in this track gain six months of rural experience. Funding opportunities through the Wisconsin Rural Physician Residency Assistance Program allow for the creation and ongoing support of rural residency tracks across Wisconsin.

Data heavily support the creation of these programs and the allocation of the required resources. The amount of rural exposure during medical school and residency has a direct impact on rural physician placement. It has been estimated that at least 50% of family medicine residency program graduates may enter rural practice if they receive 12 to 24 weeks of training in rural settings.6 Still, many factors impact rural placement and retention, including less-modifiable factors, such as a significant other’s wishes.7

A personal rural background is one of the strongest predictors of future rural practice. It is critical to create and sustain effective pathways that expose students from rural backgrounds to career opportunities in medicine as early as middle school and high school. Wisconsin’s strong network of regional Area Health Education Centers exposes more than 5,000 high school and undergraduate learners annually to health care career-mentoring opportunities. The SMPH’s Wisconsin Academy for Rural Medicine (WARM) recruits medical students who intend to practice in rural Wisconsin, and participants are largely from rural Wisconsin backgrounds. Ninety-one percent of WARM graduates are practicing in Wisconsin, and 52% are practicing in primary care.

STATE AND NATIONAL PARTNERSHIPS

Success in this endeavor depends on a strong network of dedicated partners. Rural program leaders at the SMPH benefit from, and contribute to, statewide and national partnerships in these efforts. Within Wisconsin, we enjoy wonderful, crucial relationships with the Wisconsin Hospital Association, the Wisconsin Collaborative for Rural Graduate Medical Education, the Wisconsin Office of Rural Health, and the Wisconsin DHS. These partnerships provide a rich environment for professional development, funding, and curriculum development and share a mission-driven commitment to enhancing health care for people in rural Wisconsin. Faculty leaders of our rural programs have key relationships with national organizations, including the Rural Training Track Collaborative, and hold prominent positions within the Health Resources and Services Administration’s Rural Residency Program Development Technical Assistance Center. Our SMPH program leaders are disseminating throughout the United States the lessons they have learned over decades of developing rural residency training in Wisconsin, with the goal of promoting rural residencies across all medical specialties. This is truly the Wisconsin Idea at work—promoting improved health of rural communities in Wisconsin and beyond.

THE FUTURE

The projected shortage of health care providers will continue to significantly affect rural areas. We must continue to use our time, talents, human and financial resources, and shared knowledge to build and expand the entire pathway of rural physician development, starting in K-12 programs, extending through college and medical student recruitment, and with a growing emphasis on rural residency training programs.8 The SMPH is fully committed to working with our partners in advancing this vision for Wisconsin, in a way that will serve as a national model. Together, we will move FORWARD! in advancing the health of our rural communities.

REFERENCES
  1. Painting the Picture of Wisconsin’s Health: Wisconsin’s 2020 Statewide Health Assessment. Wisconsin Department of Health Services, Division of Public Health; 2022. P-03169. Accessed March 13, 2023. https://dhs.wisconsin.gov/publications/p03169.pdf
  2. Rural Wisconsin Health. Wisconsin Office of Rural Health; 2017. Accessed March 19, 2023. https://worh.org/wp-content/uploads/2022/01/Rural-WI-Health-2017.pdf
  3. A Just Recovery of Rural Equity in Wisconsin. Wisconsin Community and Rural Response Task Force Report. University of Wisconsin Population Health Institute; 2021. Accessed: March 19. 2023. https://uwphi.pophealth.wisc.edu/wp-content/uploads/sites/316/2021/02/A-Just-Recovery-for-Rural-Equity_FINAL.pdf
  4. Topchik M, Gross K, Pinette M, Brown T, Balfour B, Kein H. The Rural Health Safety Net Under Pressure: Rural Hospital Vulnerability. The Chartis Center for Rural Health; 2020. Accessed March 19, 2023. www.chartis.com/sites/default/files/documents/Rural%20Hospital%20Vulnerability-The%20Chartis%20Group.pdf
  5. Obstetric Delivery Services and Workforce in Rural Wisconsin Hospitals. Wisconsin Office of Rural Health; 2019. Accessed March 19, 2023. https://worh.org/wp-content/uploads/2019/09/ObstetricServicesReport2018Revised.pdf
  6. Bowman RC, Penrod JD. Family practice residency programs and the graduation of rural family physicians. Fam Med. 1998;30(4):288-292.
  7. Morken C, Bruksch-Meck K, Crouse B, Traxler K. Factors influencing rural physician retention following completion of a rural training track family medicine residency program. WMJ. 2018;117(5):208-210.
  8. Crouse B, Golden RN. A strategic approach to addressing the rural Wisconsin physician shortage. WMJ. 2016;115(4): 210-211.
Author Affiliations: Jillian Landeck, MD, is assistant professor and director of the rural health equity track in the Department of Family Medicine and Community Health, University of Wisconsin (UW) School of Medicine and Public Health. Ryan J. Spencer, MD, MS, FACOG, is associate professor and director of the obstetrics and gynecology residency and gynecologic oncology fellowship in the Department of Obstetrics and Gynecology, UW School of Medicine and Public Health. Robert N. Golden, MD, is dean of the UW School of Medicine and Public Health and vice chancellor for medical affairs at UW-Madison.
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