Meeting Rural Health Needs: Interprofessional Practice or Public Health?

Abstract

Since the era of the Flexner Report, medical leaders in the United States have worried about the gap between rural and urban medical care: disparities in access to care; a shortage of physicians, hospitals, and associated health professionals in rural areas; and a perceived lower quality of care with implications for poorer health status in the countryside. Urban-rural disparities were of renewed concern after World War II as older country physicians retired or died, while newly demobilized military physicians chose to pursue specialty residencies and establish urban practices. Concern evolved into a fear that the inability of America's private medical system to provide equal care to all citizens regardless of geographic location would be a persuasive argument for government intervention in medical care in the form of national health insurance.1 The medical profession responded by developing state plans to address the rural health crisis. This essay demonstrates that, over time, federal and state plans shifted from a simple quantitative approach-expanding medical schools and hospitals to produce more physicians in the hope that at least some of them would choose to practice in a remote area-to policies promoting new health professions and interprofessional teams for health-care delivery. The latter were innovations and necessary compromises aimed at meeting the needs of underserved areas pragmatically and efficiently. However, the potential success of these policies was undercut by the lack of any mechanism to mandate the distribution of physicians and health personnel according to the nation's health needs.2Federal programs, such as the Hill-Burton Hospital Construction Act of 1946 and, later, Medicare and Medicaid, increased the physical infrastructure for rural medical care and economic access to care, but they exacerbated the demand for services without resolving the low supply of health professionals in rural areas.3 By the 1960s, state and federal manpower (workforce) plans encouraged the expansion of health professional training programs, offered incentives for rural practice, created new hybrid health professions and regional interprofessional health-care delivery services, and experimented with expanded public health nursing in doctorless towns.4 This article argues that in spite of these new programs for training and health-care delivery, physicians' political selfprotectionism from the local to the national level worked to maintain traditional professional hierarchies. Moreover, in underserved areas, physicians' power often reduced interprofessional innovations to something akin to public health nursing.Community Health Centers and Physician ExtendersOne of the chief aims of the Hill-Burton Hospital Survey and Construction Act of 1946 was to address the need for rural hospital facilities that could serve simultaneously as sites of modern medical care and inducement for physicians to locate in the countryside. Quietly, however, medical leadership acknowledged the poor likelihood of securing adequate numbers of physicians, nurses, laboratory technicians, and dentists for rural practice on a voluntary basis, regardless of the incentives.5 Medical leaders and legislators in North Carolina, a state in which three-quarters of the population lived in open country or towns of 2,500 or fewer in 1947, attempted to triage the doctor shortage by adopting the community health center as a site of interprofessional care in medically underserved rural counties. Precedents for this model of primary care delivery dated back to the Milbank Memorial Fund's New York State health demonstrations and urban community health centers in the 1920s.6 Farm Security Administration [FSA] clinics built during the Great Depression in forty communities used full-time nurses as physician extenders to supplement part-time salaried physicians. Clinician-historian Michael Grey has argued that the interdisciplinary approach of these clinics and the FSA cooperative health programs were precursors of the later community health center movement. …