In January 2017, the Minnesota State Demographic Center published the report Greater Minnesota: Refined & Revisited. The 68-page document took a hard look at the state outside the population hub of the metro area in order to identify trends driven by Minnesotas changing demographics.

Among the most significant is that Greater Minnesotans are aging faster than their urban counterparts. The findings noted residents of rural and small-town Minnesota are more than twice as likely to be age 80 or older than residents in urban parts of the state. More than 1 in 20 residents in rural and small-town areas in Minnesota were 80 or above, and 44 percent of rural residents were over 50 at the time of the report, compared to 32 percent of urban dwellers.

Unfortunately, as individuals age, they need more health care services, but rural residents are finding fewer care providers available to them. They also report higher rates of perceived fair and poor health and face higher mortality rates than do their urban counterparts. Thats according to the 2017 Minnesota Department of Healths Office of Rural Health publication, Snapshot of Health in Rural Minnesota.

All of those things put together just make [Greater Minnesota] a more complicated environment to provide health care in, says Carrie Henning-Smith, deputy director at the Us Rural Health Research Center, part of the Division of Health Policy and Management in the School of Public Health. Not better or worse, just more complicated.

Bringing doctors into rural Minnesota

The Us Rural Health Research Center studies access to and quality of health care and population health outcomes in rural areas. Its one of seven such health research centers across the country funded by the federal government to improve health outcomes in areas that have unequal access to providers, compared to more urban locations.

Although areas in Greater Minnesota with larger cities such as St. Cloud, Rochester, Duluth, or Mankato have robust health care systems that are easily accessible to nearby residents, more rural areas of the state do not. And as residents in those areas age, they often must travel farther and farther to seek health care.

During a recent trip to Worthington, a town of roughly 12,500 located in far southwestern Minnesota, U of M President Joan Gabel says one of the things she heard from local residents is that they need more help bringing doctors to the area. They asked her if there were ways in which the U could facilitate that?

Henning-Smith says recruiting health care providers to rural clinics is harder now than it was decades ago. Part of the reason is because those providers cant be as flexible in their daily practice as they can in bigger cities.

You cant specialize in any one particular population or health problem, Henning-Smith says about providers in smaller communities. You need to be able to do the full range of practice, and health providers arent always comfortable with that.

That full range of practice is often delivered by primary care doctors, who offer routine, preventative services on a regular basis, and also help patients better navigate the complex health care system. But according to the federal Health Resources & Services Administration, which tracks what are known as Health Professional Shortage Areas, Minnesota has 133 areas with a shortage of medical professionals, including primary care physicians. Only two such areas are in the metro the rest are in Greater Minnesota.

The HRSA lists Lonsdale/Erin/Shieldsville in Rice County, Oshawa in Nicollet County and St. Mary in Waseca County as medically underserved areas. Nearly every Minnesota county aside from the Twin Cities metro and Rochester area is listed as having to have a shortage of mental-health professionals as determined by federal guidelines.

Ironically, at the same time the state notes a shortage of doctors in Greater Minnesota, it also estimates there are between 250 and 400 foreign-trained doctors who cannot practice medicine here without first completing a U.S. residency. And finding a residency in the U.S. can be expensive, time-consuming, and difficult for a physician who may not be a native English speaker or familiar with this countrys medical requirements.

As a first step to helping foreign-trained doctors qualify for a U.S. residency, the U offers a program called BRIIDGE, or Bridge to Residency for Immigrant International Doctor Graduates through clinical Experience. This nine-month program is open to individuals who have a medical doctors degree or the international equivalent; who were born outside the U.S., but who have been permanent, lawful residents of Minnesota for at least two years; and who meet other requirements. BRIIDGE helps those who qualify complete pre-residency requirements so they can proceed to the next step in seeking U.S. licensure.

Michael Westerhaus, M.D., an assistant professor at the U of M Twin Cities campus and director of the program, says that in the first year, four out of four participants in BRIIDGE matched into Minnesota-based residencies. In year two, two of six have so far matched into residencies; the other four are currently applying.

Another related program in which the University participates, the International Medical Graduate Program, offers funding to help international doctors pursue their residencies. IMG was started by the Minnesota Department of Healths Office of Rural Health and Primary Care and currently funds six residency positions, three of which are at the medical school. Students who receive funding agree to work for five years in one of the states underserved areas after they complete their schooling.

Khaled Mohammed, M.D., who attended medical school in his native Egypt, is a current IMG-funded resident who expects to graduate from the medical school next spring. After 10 years of training in his home country, Mohammed came to the U.S. in 2011 for a research scholarship at the University of Pittsburgh. He went to the Mayo Clinic for a research fellowship in 2013, then enrolled in his residency at the U of M in 2017.

While his first two years in residency kept him in rotations in the Twin Cities, for his last year, he is planning an elective rotation in rural Minnesota, although hes not sure where yet. How that rotation goes will factor into where he practices after graduation. (He could also stay in the metro to practice in an underserved area through Childrens Hospitals and Clinics of Minnesota and Hennepin Health care.)

After Im done with my elective, I will have an understanding about practicing in rural settings, Mohammed says.

Another program the U offers to help introduce medical professionals to practice areas in Greater Minnesota is the Rural Physician Associate Program (RPAP). RPAP was established in 1971 as a collaboration between the medical school and the Minnesota Legislature, in response to a shortage of medical providers in rural parts of the state even then.

Kirby Clark is a family physician who has been leading the program for the last two years. He said medical education has long been very metro-centric. The point of RPAP can be summed up in a quote that Clark attributes to the late Jack Verby, another family doctor who helped establish the program: You dont train somebody to work in forestry by training them in a lumberyard.

Clark explains: You want to get [students] serving in a community, learning in a community that looks like where theyre going to practice. RPAP places third-year medical school students on rotations for nine months in clinics across the state. Positions stretch from as far north as Roseau, near the Canadian border, to as far south as Luverne, near the South Dakota and Iowa borders. RPAP is optional, but allows students to meet their third-year requirements. Roughly 35 students, or 20 percent of the U of M-Twin Cities class, participate in the program each year.

Clark adds that about 50 percent of students who participate in RPAP will go on to work in rural clinics after residency.

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