Independent primary care doctors see banding together as one way to remain solvent and keep their autonomy

Valley Medical Group joined an IPA to help regain its
financial footing. (New England Public Media photo)

As the number of primary care doctors in the U.S. continues to decrease, the number of independent primary care practices has also fallen. A practice in the Connecticut River Valley, Valley Medical Group, has sought to maintain its independence while boosting its bottom line by joining with other independent primary physicians, reports Karen Brown of New England Public Media.

Founded during the 1990s, Valley Medical Group has become one of the "largest independent practices in western Massachusetts," Brown writes. But the practice's patient volume and focus on quality family medical care haven't shielded it from the financial pitfalls of the American insurance payment system, which rewards specialists and physicians who perform procedures over primary care.

Valley Medical Group owners found themselves stuck in insurance contracts that didn't pay well or accurately. "In January, the practice laid off 40 employees — 10% of its 400-person staff — mostly in support positions," Brown writes. "Thousands of primary care practices, a key gateway to the medical system, are fighting to remain financially viable — and independent."

VMG doctors also wanted to avoid selling their practice to a hospital, which would likely take away some of their clinical autonomy. Instead, the group opted to join an Independent Physician Association. Brown explains, "Like a union, an IPA combines individual primary care offices, giving them power in numbers when negotiating contracts with Medicaid, Medicare, and private insurance companies."

While not all IPAs are equal -- some are owned by hospitals or private equity funds -- most help level the financial playing field for smaller practices. According to Brown, when independent practices band together, they can accept insurance contracts that pay them a per-patient allotment rather than billing for each visit or procedure.

Chris Kryder, CEO of Arches Medical IPA in Cambridge, Massachusetts, told Brown, "If we keep people out of the ER, keep them out of unnecessary hospitalizations, we save money for the system. . . And we create more income for the primary care providers, which is dreadfully needed."

Waves of American doctors and nurses leave their practices and head to Canada to avoid U.S. political climate

Often born and trained in the U.S., many nurses and doctors are leaving the U.S. for Canada.
(Graphic by Oona Zenda, KFF Health News)

At a time when Americans can least afford to lose medical professionals, many are leaving the U.S., citing the country's current political climate as their reason for leaving. In rural parts of the U.S., already facing a chronic shortage of medical care providers, the loss of any medical professionals makes accessing care more difficult.

"American nurses, doctors, and other health care workers moving to Canada, and specifically British Columbia, where more than 1,000 U.S.-trained nurses have been approved to work since April 2025," Brett Kelman of KFF Health News reports. 

Justin and Amy Miller from Wisconsin serve as one example. They are both nurses who were born in the U.S. and trained at American schools, but didn't want to stay in the U.S. because of policies and cuts by the Trump administration, Kelman explains. They moved their family of five to Canada, where they found new nursing jobs.

As the Trump administration systematically slashed "funding for public health, insurance, and medical research, many nurses have felt the draw of Canada’s progressive politics, friendly reputation, and universal health care system," Kelman reports.

For U.S.-trained nurses, Canada is rolling out the welcome wagon. "Ontario and British Columbia have streamlined the licensing process for American nurses since Trump returned to the White House," Kelman writes. British Columbia also launched a $5 million advertising campaign last year to recruit nurses from California, Oregon, and Washington state."

Doctors are leaving as well. "Michael, an emergency room doctor who was born, raised, and trained in the United States, packed up his family and got out," Kelman reports. KFF did not use his last name because he expressed concerns about reprisals if he returned to the U.S. 

Rural Canadians, who also struggle with accessing medical care, are also hoping to attract some American medical professionals. Doctors Manitoba, which "represents physicians in the rural province that struggles with one of Canada’s worst doctor shortages, launched a recruiting campaign after the election to capitalize on Trump and the rise of far-right politics in the U.S," Kelman writes. 

Opinion: Rural Americans rely on immigrant physicians for care, but new restrictions will leave them with fewer doctors

Rural hospitals have relied on foreign-born doctors
to provide care for decades. (MedPage Today photo)

Rural communities already struggle to staff their hospitals and clinics with physicians of all types, from specialists to family practitioners. The Trump administration's failure to make progress on immigration changes and the newly established $100,000 fee for each new H-1B visa application, which has no exemption for health care workers, will leave rural Americans with far fewer doctors to treat them, writes Manav Midha in his opinion for MedPage Today.

The difference in the number of physicians and the availability of specialists between urban and rural locations is stark. Midha writes, "There are approximately 263 specialists for every 100,000 people in urban areas compared to 30 for every 100,000 people in rural areas, and 46% of counties (and 86% of rural counties) have not a single cardiologist."

For decades, rural communities have relied on immigrant doctors for their care. Midha explains, "Foreign-born physicians are uniquely willing to serve rural communities even when few others move there. Immigration restrictions risk cutting off one of the last remaining lifelines for rural healthcare access."

Immigrant doctors who came to the U.S. in the 1980s and 1990s were able to obtain J-1 visas, which "allow for a path to permanent residency if a doctor works for at least 3 years in an area with underserved healthcare needs," Midha adds. They cared for patients in "rural Indiana, deep Appalachia, coastal Louisiana, and parts of Texas, hours from the closest city," where few American graduates wanted to live.

Congress could expand the Conrad 30 program to add some physicians with J-1 waivers who can treat in rural communities. "The bipartisan Conrad State 30 and Physician Access Reauthorization Act would have expanded (albeit slightly) the number of spots and extended the program. It was initially introduced in Congress in 2023 and again in 2025 but has seen little movement," Midha writes.

In the face of the current shortage, some states are developing their own approaches to help rural communities secure access to doctors. Midha writes, "At least 18 states, led by Tennessee, have enacted laws permitting internationally-trained physicians with appropriate experience to practice medicine without having to repeat medical residency."

Meanwhile, some rural communities may face a more severe shortage of physicians, and residents will have to travel longer distances for care. Expanding and developing paths for immigrant physicians "is not merely a moral imperative -- it is an economic one," Midha adds. "And it is one that can address one of the greatest challenges to equitable care."

New doctors are avoiding abortion ban states, new analysis shows. Restrictions may add to mutiple-care shortages.

Fewer new doctors are applying for residency in
abortion ban states. (Hush Naidoo Jade photo, Unsplash)

States with significant restrictions or bans on  abortions may be inadvertently discouraging graduating medical students from applying for residency in their state, which could exacerbate regional physician shortages. Julie Rovner and Rachana Pradhan of KFF Health News report, "According to new statistics from the Association of American Medical Colleges, for the second year in a row, students graduating from U.S. medical schools were less likely to apply this year for residency positions in states with abortion bans and other significant abortion restrictions."

State battles over abortion aren't limited to uncertainties for doctors and pregnant patients; the tensions have "also bled into the world of medical education, forcing some new doctors to factor state abortion laws into their decisions about where to begin their careers," Rovner and Pradhan write. "Fourteen states, primarily in the Midwest and South, have banned nearly all abortions. . . . A preliminary review of a new analysis by the AAMC found that the number of applicants to residency programs in states with near-total abortion bans declined by 4.2%, compared with a 0.6% drop in states where abortion remains legal."

The AAMC's analysis shows that when new doctors start avoiding certain states, those states gain fewer doctors, which adds to regional physician shortages in many specialties. KFF Health News reports, "The organization tracked a larger decrease in interest in residencies in states with abortion restrictions not only among those in specialties most likely to treat pregnant patients, like OB-GYNs and emergency room doctors, but also among aspiring doctors in other specialties."

The number of new doctors applying for OB-GYN and internal medicine residency slots in those states "dropped 6.7%, compared with a 0.4% increase in states where abortion remains legal," Rovner and Pradhan explain. "For internal medicine, the drop observed in abortion ban states was over five times as much as in states where abortion is legal."

Incoming president of American Medical Association says AMA cares about getting more doctors in rural areas

With new research showing rural Americans are more likely to die early from the five leading causes of death than their urban counterparts, "the American Medical Association is sounding the alarm," reports Melissa Patrick of Kentucky Health News.

AMA President-elect Bruce Scott (AMA photo)

"Rural health is America's health," Dr. Bruce Scott, the AMA president-elect, told reporters in a May 9 press conference in conjunction with the National Rural Health Association annual conference in New Orleans. "We need policymakers to understand that the American Medical Association is deeply concerned about the ever-widening health disparities between urban and rural communities, disparities that are at the root of why rural Americans suffered disproportionately high rates of heart disease, cancer, stroke, respiratory illness, diabetes, and unintentional injuries." 

Scott, who is board-certified in both otolaryngology and facial plastic surgery, will become AMA president in June. He pointed to several environmental, economic and social factors factors that put people who live in rural communities at a higher risk of death from these often preventable conditions. But the AMA's focus, he said, is on the health-care worker and the physician shortage and how this affects rural people's health. 

He added that these shortages are hitting rural areas the largest and are "creating health-care trends that are simply unacceptable. We need to reverse these trends for all individuals to live a long, healthy and active life." Scott said rural areas have about 30 physician specialists for every 100,000 residents, compared to 236 per 100,000 in urban communities, and he noted that more than 130 rural hospitals closed from 2010 to 2021, with many more on the verge of closing today. 

Also, he said that in 2023, 65% of rural communities had insufficient access to primary-care physicians, including pediatricians. And, he said there are not enough residency spots to train doctors in rural areas. "History has shown us that residents, 80% of the time, tend to wind up practicing within 80 miles of where they've done the residency," Scott said. "So residency location becomes very important. In addition, medical schools are receiving fewer and fewer applicants from individuals from rural areas."

Opinion: Recruiting physicians to rural areas needs to show what communities offer, which goes far beyond money

Rural medicine is often more about relationships than diagnoses,
which is a hard concept to incentivize. (UIC photo)

Student loan reductions and payoffs have not enticed enough graduating doctors to move into rural areas. But when medical providers experience working in less populated places, they often find smaller communities have so much more to offer, writes Arjun V.K. Sharma in his essay for Undark. "Strategies to attract doctors to rural areas can take many forms, but it is hard to imagine any being successful without the doctor seeing the benefits of the community in which they reside."

Government officials, public policy writers and community planners would do well to look at what it takes for a resident to opt to live in a rural location. Sharma explains: "Often, it is interminably fraught — already hard work is made harder, significant others are uprooted, and certain city comforts and sensibilities may be sacrificed. Physicians, then, must rely on forces internally summoned — autonomy, altruism, competence — to propel them forward. These qualities are harder to define and measure, which make them difficult to meaningfully pin to any reward."

"When I left the city for work in a rural hospital, I put those virtues to the test. I was unsettled, initially wading through the steady stream of 'hellos,' 'good mornings,' and 'good nights' from passersby in the corridor, and unsure of how to interact with psychiatric patients who ran a café near their small ward to ease their transition to the world outside," Sharma writes. "And I was uneasy, at times, with the care we provided — even if patients were appreciative of what they received. The same decisions we fashioned in the city — to get antibiotics delivered at home or to get a surgeon to clear out an abscess — came together with fewer resources, and with doctors stretched hundreds of miles apart."

Rural settings offer a space where all people intermingle and get to know each other. And the closeness of being together while all others are miles away "lent a power to something decidedly tangible. Interactions with patients had an unflinching honesty and tenderness about them," Sharma adds. "One morning, an older man with anxiety was referred from the emergency department to a senior physician. They ran into each other at the grocery store and at local hockey games; living down the street, the physician would often check in on him."

Sharma writes. "A connection to a rural identity could be bought with incentives, or it could be learned. . . . It could be lived through simple and heartfelt things: a teary 'thank you,' a firm handshake, or the question, over and again, from patients of your plans to stay. These gestures don’t absolve the system of its responsibility to make positive reforms. But they affirm value and purpose of work that, whittled down by staffing shortages and burnout, can still impact lives our society willfully neglects."

Fixing the rural physician shortage can begin with adding more federal and state funded residency slots

When residency slots increase, the number of
rural physicians can increase. (UICOMP photo)

By any measure, rural America is hurting for physicians, but more broadly, the nation doesn't have enough doctors. While U.S. medical schools have increased their enrollments, hospitals have yet to increase their number of residency slots, reports Brenna Miller of the Lown Institute, a nonpartisan health think tank.

"Medical school enrollment has been consistently growing, but funding for residency slots hasn't caught up. For every medical school graduate looking for a resident position, there have been between 0.8 and 0.85 slots available in recent years. This a problem as states require at least one year of hospital residency as a licensing requirement."

Without intervention, rural physicians will become increasingly scarce. "Rural areas face the brunt of this shortage as urban areas have higher densities of primary care physicians and specialists," Miller writes. "Patients in rural areas tend to be older, poorer, and sicker, especially with chronic conditions. With fewer doctors around, they have to travel further for both preventative and emergency care, putting them at greater risk for poor health outcomes and mortality."

If rural areas want more doctors in the future, there must be fundamental changes to residency funding and slot offerings. Miller explains, "The mismatch between medical school enrollment, residency slots, and the need for physicians in the workforce has resulted in a lose-lose situation where perfectly competent physicians face barriers to working while simultaneously, entire regions of the country are without sufficient access to physicians."

Some changes need to begin at the federal level. Residency slots are primarily funded by the Centers for Medicare & Medicaid Services, meaning that "they need action by the federal government for expansion. This also means that no significant action had been taken for over 20 years (Congress had actually capped the number of residents) until the Covid-19 relief bill was passed," Miller reports. "The  bill opened the door for 1,000 new residency slots, 10% of which must be in rural areas. Another similar bill has been introduced in Congress that would allocate funding for an additional 2,000 residency slots every year for seven years starting in 2025."

State funding is an additional option. Miller reports, "The majority of doctors stay in the states where they completed their residency. Both California and Texas – where the shortage is predicted to be the worst – approved multimillion-dollar expansions in funding, resulting in increased retention of physicians in underserved, local areas."

U.S. physician shortages expected to increase dramatically as older doctors retire or quit because of heavy workloads

Lack of doctors will mean a sicker population.
(Photo by J.C. Gellidon, Unsplash)

U.S. physician shortages are expected to increase substantially as aging doctors retire or extreme workloads push them out. "As the aging population's need for care grows, retirement and burnout are both driving swaths of health care workers out of the field, fueling a crisis that shows no signs of stopping,"  reports Alejandra O'Connell-Domenech of The Hill. "The country is expected to suffer a shortage of up to 124,000 physicians in the next 12 years, according to a 2019 report from the Association of American Medical Colleges." American Medical Association President Jesse Ehrenfeld told O'Connell-Domenech: "When people don't have access to routine primary care and preventative services [due to no physician access], they live sicker and die younger. . . . These are things that are only going to get worse as we put more pressure on the physician workforce." In many rural areas, the lack of doctors is already a stark reality.

If there aren't enough physicians, those who are working will have to work longer hours with sicker patients, which leads to burnout and more doctors deciding to retire or leave medicine altogether. "A 2022 study found that nearly 63 percent of physicians experienced symptoms of burnout by the end of 2021, representing a 19 percent increase from 2017," O'Connell-Domenech reports. "Another 2022 study determined that one out of five doctors said they were likely to leave their current practice within two years, citing burnout and workload as two major reasons."

The numbers explain another reason for the shortage. "There are about 55.8 million people aged 65 and older in the United States, according to Census Bureau," O'Connell-Domenech explains. "Their numbers are growing and will continue to do so. . . . Almost half of working physicians in the United States are 55 and older, according to the AMA. Thirty-five percent of the physician workforce will reach retirement age within the next five years."

Possible solutions include lessening student loan debt and increasing the number of physicians allowed to train. "The Resident Physician Shortage Reduction Act of 2023 could help by lifting the cap on residency programs," O'Connell-Domenech adds. "The bill. . . would expand the number of Medicare-supported medical residency positions by 14,000 over seven years. . . . Another piece of legislation that could help stem the shortage is the Conrad State 30 and Physician Access Reauthorization Act, according to Ehrenfeld. Under the bill, international doctors could stay in the U.S. after their residency programs as long as they committed to practicing medicine in parts of the country with physician shortages. . . . Easing medical student debt could also potentially increase the amount of doctors willing to work in underserved areas, Ehrenfeld said."

Rural doctors have to do it all, from snake bites to meat-stuck-in-throat; video looks at challenges of rural medicine

Amid a national physician shortage, getting a doctor to practice in a rural place has never been more challenging, and as rural hospitals close, the lack of providers is predicted to worsen, reports Hyacinth Empinado of STAT. "In 2023, 65% of rural areas had a shortage of primary care physicians, according to a report published by the Health Resources and Services Administration. More than 15% of Americans — about 46 million — live in rural areas, but only 10% of doctors practice in these communities, many of whom are primary care and family physicians."

Meeting the medical needs of 46 million Americans is a big undertaking. And because there are so few doctors, each has to work harder to tackle vastly different medical illnesses and accidents with limited resources. In this short documentary, STAT explores why the shortage exists and "shows what life is like for a doctor in Kansas who wears many hats and a physician in Illinois pondering retirement."

As rural communities lose physicians, a creative "patchwork" of care can emerge

An OnMed health kiosk uses high tech, remote care.
(Photo by Arielle Zionts, KFF Health News)

Rural patients are more likely to face medical provider shortages, and these communities have to find new ways to provide care. In LaFayette, Alabama, "Terry Vester and her husband, Al, are the only primary care doctors in the town of 2,700 residents, surrounded by farms and other small communities," reports Arielle Zionts of KFF Health News. "The Vesters are in their late 60s and would like to retire soon. Terry Vester wants to spend more time with her grandson and aging parents. But she can't imagine abandoning her patients, some of whom she has cared for since they were born."

Attracting new physicians is challenging for LaFayette, which is not a wealthy town with the amenities many doctors seek. Residents have a median income of $39,077, compared to the state's $59,910. "Black residents — who make up 70% of the population — are much more likely to live in poverty than white residents," Zionts writes. "The Vesters have worked in LaFayette since the early 1980s and saw the local hospital close in 1988. The nearest emergency room is now in another town 20 minutes away along a rolling road. So are the nearest urgent care clinic and pediatrician's office."

With those barriers in mind, town residents who need medical advice have turned to "the city fire department, staffed with full-time firefighters and emergency medics," Zionts reports. "People from LaFayette regularly walk or drive themselves to the fire station to ask for help, said Fire Chief Jim Doody. He added that the station has a makeshift exam area within its small entryway, containing a bench, defibrillator machine, and cabinet filled with medical supplies. . . .This de facto walk-in clinic option isn't available in most other rural areas, where emergency medical services are often run by volunteers who aren't posted at a station all day, Doody said. But he's noticed fewer LaFayette residents relying on the fire department since a new telehealth service arrived in town."

OnMed telehealth kiosk service opened in LaFayette to meet basic medical needs. Patients can head into a computerized booth, press a button and see "a nurse practitioner appear on a large vertical video screen positioned at eye level," Zionts explains. "OnMed patients use an automated blood pressure cuff and other devices to collect their vital signs, and the data is sent to the provider treating them from a distance. Patients can also hold a stethoscope to their chest to transmit the sounds of their heart and lungs. A special camera captures internal temperatures, which can be used to diagnose infections. A hand-held camera lets providers examine problems such as rashes, irritated eyes, and swollen throats. In some states, the stations can dispense medications."

While Vester spoke positively about OnMed services, she feels "It's still important to have doctors in town," Zionts reports. "Vester plans to reach out to Alabama medical schools to let them know she's looking for doctors to take over for her and her husband."

Finding more physicians for rural America: Appalachian doctor looks for students with a 'passion for healing'

Anya Cope, D.O., believes career options ought to be offered to rural
students before high school. (Courtesy photo via The Yonder)

What's the best way to attract physicians to practice in rural America? Find ways to plant the idea in rural youth and then nurture them. That's what Anya Cope, a doctor of osteopathy from Dryden, Va. (pop. 878), does at Lincoln Memorial University in Harrogate, Tenn., reports Taylor Sisk of The Daily Yonder. "Cope is an associate dean of clinical affairs and an assistant professor of internal medicine at LMU's DeBusk College of Osteopathic Medicine. . . . Described by a colleague as 'a fixer; a doer,'[Cope is] a living example; through her instruction, she demonstrates how to excel in a demanding field when the odds appear to be against you."

Cope's father was a coal miner, and her mother a power-company employee, Sisk writes: "She graduated from high school in 2000. It was, she says, a 'weird time' in the mountains of rural Southwest Virginia: The over-prescription of opioids had taken deep root across generations. . . . She considers her education. . . to have been sufficient; she was prepared to be successful at college. But the family had no real knowledge of or resources for board prep courses. Her Medical College Admission Test score, she says, wouldn't get her into med school today. . . . Cope believes schools too often put too much emphasis on standardized testing. . . . She urges administrators to look beyond that number. It tells you nothing about a potential student's determination, their passion for healing."

Cope spends time doing outreach in the region's undergraduate colleges, Sisk writes, but "the outreach, she believes, must start early." Cope told her, "Too many kids in this region think their only options are coal mining, teaching, and nursing – all of which are commendable careers – or illegal drug dealing. You can't be it if you don't see it. We need to show them there are other options – that there are people from here who are succeeding in all kinds of fields. And it has to be before high school." Sisk reports, "Toward that end, the college is setting up camps for pre-K through eighth-grade students that will offer opportunities to study Science, Technology, Engineering and Math topics, explore career choices, and gain skills necessary to be successful in those fields."

Cope's other role includes forging connections with hospital staffs, high schoolers and undergraduate students. Cope told Sisk, "My job is all about relationships. . . . [she is looking for] someone who is adaptable. Someone who, despite facing adversity, has been able to keep going. Someone who has shown a commitment to medicine and a passion for medicine. . . . Of course, we want someone who is drawn to Appalachia and to rural medicine. But I think that even those who have not had the experience of rural medicine, once they get here, we can convince them."

Research supports her approach: "A 2021 Journal of Graduate Medical Education study found that 'Physicians often practice within 100 miles of where they completed residency' and 'Training residents where they are needed in practice is one promising strategy to increase the supply of rural physicians," Siskk reports. "Personally, she's driven to underscore for those from rural communities that 'you can be just as good as any others – and maybe better because of the resistance you've had to fight against. It's like cross-training: fighting against resistance makes you stronger.'"

Different initials, but education and care are the same; osteopaths, or D.O.s, are filling a rural void with 'their thing'

Kevin De Regnier, an osteopathic physician in Winterset, Iowa,
examines Alice Collins. (KFF Health News photo by Tony Leys)

In rural America, you may be more likely to be treated by a "Doctor of Osteopathic Medicine," or D.O., instead of an M.D., but their schooling and boarding tests are alike," reports Tony Leys of KFF Health News. "Osteopathic physicians go to separate medical schools from medical doctors. . . . Their courses include lessons on how to physically manipulate the body to ease discomfort. But their training is otherwise comparable, leaders in both wings of the profession say. . . . Both types of doctors are licensed to practice the full range of medicine, and many patients would find little difference between them aside from the initials listed after their names."

Although currently not as common, D.O. numbers are increasing, especially in rural areas, partly because new osteopathic medical schools have located in places like Pikeville, Ky., and Harrogate, Tenn. "School leaders say their locations and teaching methods help explain why many graduates wind up filling primary care jobs in smaller towns," Leys reports. "U.S. News & World Report ranks medical schools based on the percentage of graduates working in rural areas. Osteopathic schools hold three of the top four spots on the 2023 edition of that list."

"The very nature of osteopathic training emphasizes primary care. That's kind of their thing," Michael Dill, director of workforce studies at the Association of American Medical Colleges, told Leys.

Leys reports, "Data from the University of Iowa shows osteopathic physicians have been filling rural roles previously filled by medical doctors. The university's Office of Statewide Clinical Education Programs tracks the state's health care workforce, and its staff analyzed the data for KFF Health News. The analysis found that, from 2008 to 2022, the number of D.O.s based outside those urban areas [previously filled by M.D.s] increased by 29%. Because of the shift, D.O.s now make up more than a third of rural Iowa physicians, and that proportion is expected to grow."

From 1990 to 2022, "the number of osteopathic doctors more than quadrupled, from fewer than 25,000 to over 110,000, according to the Federation of State Medical Boards. Over half of D.O.s work in primary care, which includes family medicine, internal medicine, and pediatrics. By contrast, more than two-thirds of M.D.s work in other medical specialties," Leys reports.

Friday's quick hits: All's quiet with rural reticence; celebrating Nina Simone; want your own Tiny Desk concert?

Nina Simone statue in Tryon, N.C. (Photo by Annie Chester)

Born in 1933, Eunice Kathleen Waymon was born in the quaint Appalachian town of Tryon, North Carolina. A rare musical talent, Eunice's first stage was the church before she became the Black nationalist known professionally as Nina Simone, Expatalachians recalls. Simone's sultry, distinct voice made her famous, and she used her music to fight against injustice, penning songs like “Mississippi Goddamn," which was her response to a 1963 white-supremacist terror attack in Birmingham, Alabama that killed four young Black girls. She died in 2003.

Rural America has a magic that spills into its music. From Bluegrass to folk to Appalachian roots to harmonica duos, you name it, there's a unique spirit to it. Consider sharing that spirit and enter to have your own "Tiny Desk" performance. Rural has a lot to share.

On Friday, it's good to take a breath. Maybe take a moment to read Maddy Butcher's piece on
rural reticence. . . In the rural West, quiet reserve is an essential skill and a fading art form, lost on people, like me, who rush to react and to be heard. Inevitably, it is rapidly losing ground to a louder, vainer way of being. 

A bachelor’s degree in automotive restoration has put a tiny Kansas school on the map. At a time when college enrollments are diving, McPherson College’s enrollment has been steadily increasing. Because its program is unique, it can cast a wider net than other colleges its size; it has 851 students — up 18 percent over the last five years. Check out that 1953 Mercedes-Benz 300S Cabriolet and status symbols by the likes of Clark Gable, Bing Crosby, Cary Grant and Gary Cooper.

The sign said, "Flowers are the Answer." What’s not to love? Floral foam, also known as "green fine-celled thermoset phenolic plastic foam" is particularly not lovable, writes Adrienne Mason for Hakai magazine. Flowers are beautiful, they’re natural, they lift our spirits and fill interior spaces. They let us say things without having to say too much. Mason says florists need to forget foam, embrace new—or re-embrace old—techniques, and educate their customers.

The English village of Lostwithiel is looking for a new general practitioner amid a national shortage of primary-care doctors. Residents hope a music video will do the trick. See what we did there: rural people know how to use music to create some magic. And maybe, just maybe, land a new doctor.

Do you have a friend who can do six degrees of Secretariat instead of six degrees of separation? Some people do not know a person like that, or anything about horse racing. Well, giddy up! Horse racing is set to join Netflix's stable of sports documentaries. Filming on what is understood to be a four-part series on the "Race to the Kentucky Derby" is set to start next month and the casting process has begun, with the series looking to tell the stories behind the owners, trainers, breeders, and jockeys involved.

First tribally affiliated medical school in the U.S. creates a life-changing partnership for under-served communities

Medical students stand outside the College of Osteopathic Medicine
at the Cherokee Nation. (Photo by Oklahoma State University)

Nearly a decade in the making, Oklahoma State University and the Cherokee Nation have opened the country’s first tribally affiliated medical school. "The 84,000 square foot facility in Tahlequah officially opened its doors in early 2021, following half a year of virtual classes for the college’s first cohort of students," reports Gretel Kauffman for Rural Health Information Hub. "The facility itself was paid for by the Cherokee Nation, while OSU staffed the college and provided the educational technology. The school had been nearly a decade in the making, with conversations between OSU and the Cherokee Nation starting in 2012."

Amid a national physician shortage, "Oklahoma has one of the most severe doctor shortages in the nation, ranking 48th for number of active physicians per capita in 2022," Kauffman writes, "In rural parts of the state, it isn’t uncommon for a county to have one primary care provider, said Natasha Bray, dean of the College of Osteopathic Medicine at the Cherokee Nation. While telehealth has proven to be a helpful tool for some communities, it isn’t a reliable alternative for patients who lack access to high-speed internet, Bray said — and isn’t a direct substitute for in-person care."

Bray told Kauffman, "All people deserve a health-care provider who’s going to be able to be their partner and be present with them. The development of that relationship is so critical to building trust and improving care in our rural communities." Physicians who are "homegrown" are more likely to embrace rural life. Bray said, "They understand all that is amazing about living in a rural community, and they understand what the challenges are. They’re able to successfully build a practice and care for their community because they have an understanding of what’s involved in it.”

Only one in five of the students are Native American, Kauffman reports: "Roughly half hail from rural Oklahoma. Those percentages are in stark contrast to other medical schools across the U.S., where less than 5 percent of students come from rural backgrounds; that percentage drops to less than 0.5 percent for rural students from under-represented racial or ethnic minority groups. Meanwhile, American Indian and Alaska Native students account for less than 1 percent of medical students nationwide."

Bray explained the spirit of the school to Kaufmann: “When we look at success in medical education, one of the important components for avoiding burnout is your sense of belonging within a community. Having people who share your mission, your values, and your goals is extremely important — and that translates not only to individual well-being, but also to academic success.” Cassie McCoy, a second-year student, told Kauffman, “There is just this natural sense of family, and I think OSU does a really good job of promoting that and creating a culture where we can ask each other for help. You just feel that community, that sense of pride and belonging.”

Melanoma cases are more common in rural areas; one reason: lack of dermatologists, Michigan researchers say

Melanoma is the the third most-common cancer found in rural America. A new study from Cancer Reports on residents from rural Michigan that shows the frequency and deadliness of undiagnosed skin cancer among rural residents when compared to urban dwellers. "One reason for that dramatic disparity: lack of dermatologists in rural counties," reports Eric Freedman of Capital News Service in review of the report. "Michigan has almost twice the number of dermatologists per capita practicing in urban counties And 38 of the state’s 62 rural counties have no dermatologists at all."

Lead researcher Richard Shellenberger, an internal medicine specialist at Trinity Health Ann Arbor Hospital in Ypsilanti, told Freedman, “The lack of doctors in rural areas was a significant factor. It takes a special person to say, ‘I want to practice in the Upper Peninsula; I want to practice in rural Northern Lower Peninsula.’”

3D structure of a melanoma cell derived by ion abrasion
scanning electron microscopy. (Image from Unsplash)

If cancer is diagnosed late, it is more likely to be severe. Dearborn dermatologist Karen Chapel told Freedman, “The more deeply melanomas invade the skin, the higher their risk of metastasizing – spreading to internal organs – and being deadly."

Steven Daveluy, professor at the Wayne State University School of Medicine, told Freedman that rural residents are more than three times as likely to work outdoors than their urban counterparts, increasing their exposure to the sun,

While there is a national dermatologist shortage, the lack is more acutely felt in rural areas. Daveluy gave Freedman an example of a farmer he treated: "After years of sun exposure working outdoors, he found an open sore that wouldn’t heal on his scalp. He didn’t like to go to doctors, plus he was busy working his farm to keep everything running, so he delayed coming to get treatment. When he did come, the sore had grown significantly. Due to his delay in seeking care, his surgery was more extensive.”

Chapel and Shellenberger gave Freeman a short list of items that could help ease the medical care gap between rural and urban areas, which included telehealth, incentives for rural rotations by medical students, and government support for new physicians entering rural communities with a focus on specialty physicians.

Rural areas are finding new ways to overcome shortages of doctors and nurses; stories from Maine and Montana

Dr. Kaycee Gardner in Miles City, Mont. (Photo by Amy Lynn Nelson)

Rural America is set to have one of the largest physician shortages by 2030, and nurses are likewise in short supply in rural areas.

Montana is already feeling the pinch and has been looking for ways to recruit and retain young physicians. "The greatest predictors for who will become a rural physician boils down to specialty and background," reports Emily Schabacker of the Billings Gazette. "Family medicine physicians are better positioned to serve rural populations than those who opt for more specialized training. And physicians raised in rural places are more likely to return to rural places to practice, making rural recruitment more important than ever."

One challenge facing Montana has been the lack of student interaction with medical professionals and very limited opportunities for high-school students to shadow doctors. Dr. KayCee Gardner, who practices in Miles City, Mont., "grew up 35 miles south of Broadus, where only a physician’s assistant and a nurse cared for the community," Shacbacker writes. "Not knowing any doctors growing up, Gardner never thought she’d end up in the medical field. No recruitment programs or career summer camps came to her corner of Montana."

To encourage their rural physician development, RiverStone Health created the RiverStone Health MedStart camp, which "aims to expose high schoolers from rural communities to careers in medicine," Schabacker reports. Camp organizer Nikole Bakko told her, "Every county in the state has been represented at one of the five participating health centers since the camp began in 2010. . . . Rural students aren’t being exposed to (careers in medicine). With MedStart we’re able to show them opportunities they don’t typically see."

The medical-provider shortage is not limited to physicians. "Rural hospitals have endured physician shortages for decades, but the staffing dearth that followed the pandemic has made staffing challenges even worse. As a result, critical access hospitals are relying more on traveling nurses," reports Schabaker. Rich Rasmussen, CEO of Montana Hospital Association, said the high cost of traveling nurses are and expense that has threatened to sink the state’s larger hospital systems.

In Maine, the most rural state in the country, is addressing its nursing shortage and the additional costs with a "Grow Your Own" model. Eastern Maine Community College in Bangor "partners with rural hospitals to provide nursing education close to home for students who would rather not come into the city," reports Nichole Dobo of The Hechinger Report, which covers education. "Now in its sixth year, the program is helping the community college increase enrollment in a job that’s in great demand. And it is reaching students who might otherwise struggle with transportation costs (especially during a period of epically high gas prices), family responsibilities or just a preference for staying close to home."

Maine is also reaching out to more non-traditional students. Emily Thompson, "then 47, had recently re-entered the workforce as a cashier after raising her child. A woman came into the store, worried about getting gas into her car because she had forgotten her wallet. As she helped the woman with the electronic payment app on her smartphone, she noticed her name tag: Pilar Burmeister, director of the nursing program" at the college, Dobo writes. "Now, she’s looking forward to May when she plans to graduate as an R.N. and leave her cashier days behind."

The program "partners with rural hospitals to provide nursing education close to home for students who would rather not come into the city," Dobo reports. "Now in its sixth year, the program is helping the community college increase enrollment in a job that’s in great demand. And it is reaching students who might otherwise struggle with transportation costs (especially during a period of epically high gas prices), family responsibilities or just a preference for staying close to home."

Pilar Burmeister, director of the program, told Dobo, “It’s a win-win for everybody. We get to increase our rolls. Hospitals win because they get nurses. Students win on saving time and money.”

Also, "This rural focus helps community colleges train more people who are likely to stick around in the rural hospital after they graduate," Dobo notes. Thompson told her, “It is going to be a bit of a new lease on life for me. I wasn’t making a bunch of money at the store. I liked working there. But this is a real career for me.”

Congress's auditing arm says states could keep more rural delivery rooms open by raising Medicaid reimbursements

Increasing state Medicaid reimbursement rates for rural hospitals could help them keep their obstetric units open, the Government Accountability Office said in a report Wednesday.

More than half of rural counties "did not have such services in 2018, according to the most recent data available," the report notes. "Studies showed that closures were focused in rural counties that were sparsely populated, had a majority of Black or African American residents, and were considered low income."

The GAO, the auditing arm of Congress, interviewed stakeholders, who said Medicaid reimbursement and physician recruitment and retention are the most important factors in keeping delivery rooms open. "Stakeholders said Medicaid reimbursement rates set by states do not cover the full cost of providing obstetric services. This may mean particular financial losses for hospitals providing these services in rural areas, where a higher proportion of births are covered by Medicaid. Medicaid covered 50 percent of rural births in 2018, compared to 43 percent of births for the United States as a whole."

"Recruiting and retaining providers is particularly challenging for rural areas, as they must compete with urban areas for a limited pool of providers to staff obstetric units that require a full range of maternal health providers, such as physicians and nurses, as well as anesthesiologists." The report said obstetric services would also benefit from more remote consultations, such as videoconferencing, to {ensure that rural patients who live longer distances from higher levels of obstetric care have access to such care through their own clinicians in their communities."

The report also suggests "establishing regional partnerships—such as a hub-and-spoke model where a larger hospital partners with smaller rural hospitals for care coordination and to provide training and other resources. . . . For example, a specialist from the hub hospital could help manage a rural patient's high-risk condition as needed and support the rural clinician for planning delivery at the local hospital."

Innovative program, with high-school grads conditionally accepted to medical school, aims at rural doctor shortage

Marshall University's BS-to-MD program's first graduates, this year.

Rural America has a growing shortage of doctors; Marshall University in Huntington, W.Va. aims to help mitigate that shortage in the state with an innovative seven-year "BS-to-MD" program that helps promising rural students become doctors, with the understanding that they will serve in rural areas after graduation, Dr. Kay Miller Temple reports for the Rural Health Information Hub.

Here's how it works: Promising high-school students are conditionally accepted to medical school, and in the meantime are given mentoring opportunities as they earn their undergraduate degree on an accelerated schedule. Once they get their bachelor of science degree, Marshall waives their medical-school tuition, Temple reports.

The program, which began in 2015, takes 10 students a year, and has nearly 30 undergraduates and around 35 medical students. Jennifer Plymale, the medical school dean and director of the Robert C. Byrd Center for Rural Health, told Temple that while the program seeks under-served students rather than specifically rural ones, about half come from rural areas because West Virginia is largely rural. 

"About 50% of our students matched in primary-care specialties," Plymale told Temple, and added that about 30% of students matched to in-state residencies. "Both of these statistics – in addition to community of origin — are important since specialty choice and training location have been proven by research to be strong indicators of final practice type and practice site. We have great faith that when our first cohort complete their residencies, they will either practice in rural West Virginia, in rural areas of nearby states, or, if choosing an urban setting, will be more mindful of the needs of rural patients."

Rural hospitals face danger as pandemic funding runs out; 1 in 5 are at significant risk of closure or service reduction

Federal pandemic aid drastically slowed the pace of rural hospital closures. (Bipartisan Policy Center graph)

Federal pandemic aid helped slow the pace of rural hospital closures, but that aid is drying up, and the hospitals are still dealing with pandemic-driven financial problems and staffing shortages, and one-fifth are at significant risk of closure or service reduction, the Bipartisan Policy Center reports.

A new BPC report offers insights on the state of rural health care through interviews with providers, national organizations, federal and state policy experts, and rural hospital leaders in Iowa, Minnesota, Montana, Nebraska, Nevada, North Dakota, South Dakota and Wyoming.

The report focuses mostly on strengthening health-care delivery through Medicare and Medicaid, since those programs play an outsized role in rural America. Here are some highlights from the report:

• About one-third of Americans are enrolled in Medicare.
• Nearly one-quarter of Americans under age 65 rely on Medicaid as their primary health insurer.
• Many rural stakeholders said that, once federal pandemic aid dries up, many rural hospitals will once again be at risk of closure unless additional action is taken to protect them.
• Hospitals experiencing persistent financial losses (negative total operating margins over three consecutive years) ranged from 6% in Nevada to a high of 38% in Wyoming.
• Out of 2,176 rural hospitals, 441 (one-fifth) face three or more concurrent signs of financial risk that put them in danger of service reduction or closure, and 909 (42%) face two or more signs of risk. The risk signs include negative total operating margin, negative operating margin on patient services alone, negative current net assets, and negative total net assets.

Based on its interviews, the Bipartisan Policy Center recommends several short-term policies to stabilize and strengthen access to rural hospitals and health clinics:

• Provide rural hospitals full relief from across-the-board Medicare spending reductions, known as sequestration, until two years after the federal public health emergency ends.
• Take rural facilities out of the ongoing 'extender' and 'needing to be renewed' budget cycle, including by permanently authorizing the Medicare Dependent Hospital program and making rural low-volume payment adjustments permanent.
• Update or rebase Sole Community Hospital and Medicare Dependent Hospital payment structures to ensure reimbursement is in line with current costs.

The report also has a raft of recommendations to improve workforce recruitment and retention, and improve access to specific services such as ambulance care, telehealth, behavioral health, and maternal care services. Read the report here.

Analysis: Rural chronic-illness patients face four broad barriers to treatment that go beyond doctor shortages

Rural residents are more likely to have a chronic illness and more likely to die from it than their suburban and urban peers, in large part because of lack of access to health care. The longstanding shortage of doctors and nurses is partly to blame, but so are widespread barriers to access. A new analysis of 62 studies, recently published in the Annals of Family Medicine, identifies four broad barriers to access rural patients with chronic illnesses face:

• Navigating the rural environment. This includes the financial and physical costs of living far from medical care. Some patients found it difficult to stay in the car for long distances, and some said the cost of gas was prohibitive. Some patients said caregivers weren't able to drive them so far, or that they felt too guilty about the time and cost to ask for a ride. But patients and caregivers in nearly half the studies surveyed said they were willing to drive further away for care because locally available services weren't good enough.
• Navigating the health-care system. Some patients and caregivers described delays in obtaining care because there weren't enough local clinicians. Many also said it was difficult to maintain continuity of care with certain doctors or organizations because of high turnover. And many said they were frustrated with clinics' inflexible scheduling and long wait times while in the clinic (on top of the long drive there and back) that made it difficult to fit a visit into the patients' schedules.
• Financing chronic disease management. Half of the studies analyzed cited patient complaints that health-care was too expensive, when factoring in rural price hikes, the already high cost of health care, hotel and transportation costs, childcare, and time spent away from work. Participants in nearly half of studies citied competing financial priorities such as bills, childcare and other household expenses, and some patients simply accepted that they couldn't afford treatment because of the cost. Many patients who said they couldn't afford treatment said they lived in communities marked by "widespread poverty, a lack of employment opportunities, and a general sense of being 'forgotten' by policy makers." Some subgroups, especially Native Americans relying on the Indian Health Service, said lack of health-insurance coverage made treatment too expensive.
  
• Rural life. Many participants cited tight-knit rural communities as a positive aspect, but that can be a "double-edged sword" for those with highly stigmatized chronic illnesses such as HIV or mental-health disorders. Participants in 13 studies said worries about gossip and lack of privacy kept them from accessing care. Participants in about one-third of studies said that rural values of self-sufficiency and stoicism made them reluctant to seek treatment. And some patients said they felt belittled or stereotyped for being rural. Indigenous patients described western clinicians as often "paternalistic, condescending, and openly skeptical of tribal healing practices" and "inadequately versed in tribal health-related beliefs, communication preferences, and social norms"

The researchers undertook the analysis because these barriers to access haven't been well represented in studies. That's partly because it's harder to recruit and retain rural student participants, and partly because studies about rural health-care access sometimes overgeneralize about rural living, ignoring the wide variance in rural settings and lifestyles.