Longitudinal assessment of a Dental and Medical Student Service program in Appalachia: Successes and lessons learned

Abstract

Objectives:

Recruiting/retaining healthcare professionals within rural and underserved communities in the United States remains a challenge. The West Virginia University Institute for Community and Rural Health implemented a service scholarship program in 2011 to address a lack of dental and primary care.

Methods:

Dental and medical students commit to practice 12-months full time following graduation in a Health Profession Shortage Area (HPSA) or Rural Urban Commuting Area (RUCA) in West Virginia for each $25,000 received.

Results:

Since inception of the program, 20 of 23 (87 percent) dental recipients had completed their service commitment, 17 (85 percent) are still practicing in WV, and 3 (13 percent) are fulfilling their commitment. Four of 20 medical recipients have repaid (2) or fulfilled (2) program commitments and 16 are completing commitments or deferred during training. Retention rate is 82 percent for both dental and medical professionals following program completion.

Conclusions:

Service scholarships effectively engage students to provide care in rural/underserved areas and remain there after program completion.

Introduction

The placement and retention of healthcare providers in rural and underserved communities has been a constant struggle and lack of access to healthcare in these communities is related to reduced care utilization and worse outcomes.^1,2 Interventions at federal, state, and local levels by government and non-governmental organizations within and outside of the United States have had mixed success. In the United States, the National Health Service Corps (NHSC) is a Federal program, which places healthcare providers in underserved communities.³ A study from 1994 indicated that there were numerous variables, which influence the retention of a physician in an underserved community⁴; however, NHSC funding/scholarship was not a critical factor in retention of physicians. Another study of the NHSC program reported a 20 percent retention rate of physicians in rural locations.⁵ Variables that influenced rural physician retention included the specialty and assignment length. In a study examining pediatric dental residents, researchers concluded that provision of service scholarships of at least $40,000–$60,000 are likely needed for effective recruitment of pediatric dental residents to rural locations.⁶ In Georgia, it was found that a medical scholarship’s effect on recruitment and retention in rural locations increased when the repayment amount was increased to three times the amount of the original scholarship in lieu of completing the service obligation, and information about and applications for the scholarship were presented during a medical job fair.⁷ Service scholarships were found to be important for provider community choice and possible retention in the community.⁸

In Australia, the Queensland’s Health Rural Scholarship Scheme has provided scholarships to students in the allied healthcare disciplines.⁹ Scholarship recipients receive financial support for the final 2 years of their study program. Following graduation, students are required to complete a 2-year service period in a rural/remote location. An evaluation of the program showed that 70 percent of participants completed the program, 16 percent were still completing the program and 14 percent had broken their service obligation. The authors also reported that while funding and job security were important factors, the ability to serve in a rural community was a strong underlying influence on participation. This finding was replicated in New South Wales (NSW), Australia, with the NSW Rural Resident Medical Officer Cadetship Program.¹⁰ Fifty-three percent of participants continued working in rural locations and cadets reported that the program was important in deciding where to practice.

One argument that counters the apparent effectiveness of service-oriented programs is that the purported positive impact of increased density of providers in an area results in better health outcomes is not strongly supported and that the impact of higher provider density to health outcomes plateaus.^11,12 Therefore, service-oriented recruitment and retention programs are more likely to positively impact health outcomes in areas with the lowest provider density.

West Virginia (WV), located in Appalachia, is consistently at the bottom of national rankings relative to health issues and lack of primary care services, including medical and dental care.¹³ West Virginia University (WVU) dental and medical curriculum requires community-based rotations for graduation and emphasizes completion of this requirement in rural and underserved areas. The WVU Institute for Community and Rural Health implemented a service scholarship program in 2011 to address this lack of primary and dental care. This program provides funds to dental and medical students who agree to work in a rural and/or Health Professions Shortage Area (HPSA) location after graduation or completion of residency for 1 year for each $25,000 received. The program follows recipients as they enter into practice and collects objective and subjective data regarding the program and where recipients ultimately end up in practice after their service commitment. This article provides a summary of the program and retention outcomes since the program began in 2011 with a focus on rural and underserved areas with lower health provider density.

Methods

Provision of funding to health profession students with a required service commitment was created as a recruitment and retention tool. Dental and medical disciplines were identified as those with the highest deficit in the state workforce, particularly in rural areas. Dental students in their fourth year and medical students in any year are eligible to apply. Dental students are informed about the program during one class period of their Public Health Dentistry course, which occurs in the spring term of year 2, prior to the start of their required community-based rotation. Medical students are informed about the program during orientation. All students are reminded of the program during the 4-week application period by their respective programs and during an annual student rural health information fair.

All recipients are required to select and sign a contract with a community-based practice site in a HPSA or a rural area as defined by a Rural Urban Community Area (RUCA) ≥ 4 where they fulfill their commitment. The site must be within the State of West Virginia. RUCA codes are defined by the United States Department of Agriculture and a RUCA code of 4 or greater is defined as being outside of metro areas.¹² Dental students receive a one-time $50,000 award and are required to practice full time (32–40 hours per week) for a minimum of 24 months. Medical students receive $25,000 and can re-apply for a total of 4 years with each year of funding requiring a practice commitment of 12 months of full-time service (40 hours per week). Practice commitment must be within West Virginia. Awarded funds are applied directly to the student’s financial aid account to help offset the cost of dental and medical education.

Application questions regarding high school and county, rural background, experience working with underserved populations and ties to the state are collected as potential predictors of dental and medical practice intent^14,15 and included in a selection metric where these factors, as well as RUCA and HPSA scores of proposed community-based practice sites, are scored to create a ranking. A committee of 4–6 faculty and professional staff independently review and rank applicants, discuss rankings and select recipients. On average, four medical and two dental students receive funding each year, supported through a grant from the West Virginia Rural Health Initiative. It is important to note that dental students typically go directly into practice, whereas medical students still have to complete residency training, thus a lag between degree completion and entry into practice for purposes of the service component for medical students. Verification of practice commitment is completed annually through a form mailed or emailed to recipients. Heartland Educational Computer Systems, Inc. (ECSI), a student loan management company manages any defaults or repayments. Dentists or physicians who have received program funds are also tracked beyond their commitment annually through phone calls and emails. Program status is determined for all recipients using the following operational definitions: deferred (recipient has been awarded program funding and remains in their academic program in good standing or are completing a medical or dental residency program), active (recipient has completed training and is currently fulfilling commitment), fulfilled (recipient has fulfilled the required commitment and funding is forgiven), repayment (recipient has received program funds and re-payed funds without fulfilling commitment), and default (recipient received program funding and failed to complete the service commitment and repay funds). Service scholarship program data include recipients verified 2011 through 2020. The West Virginia University Institutional Review Board approved this study.

Results

Between 2011 and 2020, 23 dental and 20 medical students have been provided a total of 65 service program awards out of 35 and 50 applicants, respectively. Nineteen of 23 dental and 17 of 20 medical awardees graduated from high school in WV and 27 (62.8 percent) of all recipients were from a rural area¹² or self-identified as rural (69.8 percent). All but one dental student reported experience working with underserved populations. Thirty-nine participants (21-dental; 18-medical) reported having ties to West Virginia, and all 21 dental students indicated family ties. Table 1 details demographic variables.

Table 1.

Service Scholarship Program Participant Characteristics

	Dentistry	Medicine	Total	% Total
Gender Male	8	13	21	48.8
Female	15	7	22	51.2
High school attended
Rural-WV	13	13	26	60.5
Urban-WV	6	4	10	23.3
Rural-out of state	1	0	1	2.3
Urban-out of state	1	3	4	9.3
No response	2	0	2	4.6
Self-identified from rural background
wv	16	14	30	69.8
Out of state	1	0	1	2.3
Urban	6	6	12	27.9
Experience working with underserved populations
Yes	21	20	41	95.2
No	1	0	1	4.8
No response	1	0	1	4.8
Ties to WV
Family	21	18	39	90.7
Spouse	0	1	1	3.1
No ties	1	1	1	3.1
No response	1	0	1	3.1

Twenty of 23 (87 percent) of dental student recipients have completed their obligation and of those 20 completers, 17 (85 percent) are still practicing in West Virginia, 15 of 17 (88 percent) continue in practice at rural and/or underserved locations. Three (13 percent) of dental recipients are active. Three dental program completers had left WV at time of follow-up, all from WV and identifying as rural, and two from rural areas as defined by RUCA.¹² Eleven (55 percent) medical student recipients currently have their commitments deferred while completing medical school (n = 5), residency (n = 5), or military commitments (n = 1), and five (25 percent) are active. Three of four medical recipients (two repayment, one fulfilled) had left the state at the time of follow-up, two from WV, one from rural WV that fulfilled their commitment and now practices in arural and underserved area in another state. Overall retention rate at rural/underserved sites in WV is 82 percent for both dental (17) and medical professionals (1) following program completion. Table 2 details program status and practice designations for all program participants.

Table 2.

Current Status of Service Scholarship Program Participants

Program Status	Dentistry	Medicine	Totals		% Total
Deferred	0	11	11		25.5
Active	3	5	8		18.6
Repayment	0	2	2		4.7
Default	0	0	0		-
Fulfilled	20	2	22		51.2
Totals	23	20	43
Practice Site Characteristics for Participants with Fulfilled Program Status
Still Practicing in West Virginia
	Rural	Underserved	Rural and underserved	Not rural or underserved	Totals
Dentistry	10	15	10	2	17
Medicine	1	1	1	0	1
Practicing Out of State
Dentistry	0	1	0	2	3
Medicine	1	1	1	-	1
Totals	12	18	12	4	22

Rural = RUCA (2006) ≥ 4; Underserved determined by HPSA designation (primary care and dental as appropriate), including full county and/or facility scores as applicable.

Discussion

An 85 percent retention rate of dental providers that completed their obligations at community-based rural and underserved sites in the current program supports the use of service scholarship programs as an effective method to recruit and retain dentists in rural and underserved areas, as seen in other programs.^5,7,9 The selection process includes weighting of several factors that influence provider retention in rural and underserved areas.^3,15 Six of 15 dental program completers that remained in-state at rural and underserved sites were from rural areas as defined by RUCA. Eleven identified as coming from a rural background, indicating that perceived rural background may influence self-selection into the program and serve as a better predictor of retention than the currently used definition of rurality.¹⁴

The WVU curriculum requires all students to complete a community-based rotation with emphasis on rural or underserved areas to graduate, a factor associated with provider retention.¹⁶ A systematic review of previous studies indicates that rural background combined with required training in rural areas may be an effective way to address rural dental professional shortages.¹⁷ The amount of funding provided to dental recipients ($50,000) may also contribute to the increased interest in rural practice, falling within the range observed as appealing in previously published work.⁶ Future program evaluation that matches samples of applicants and awardees may delineate the influence of actual and perceived rural background, rurality of rotation site location, and program participation, including scholarship amount, on retention of dental providers in the state.

We received requests and provided information to two additional in-state programs on how to implement and manage a service scholarship program. In addition to the methods detailed here, we have learned Supplementary lessons from our 9 years of experience. Most notable are the revision of application questions to more accurately ascertain interest and commitment in rural practice and identify factors influencing rural and primary care practice choices.^3,15 Similar to Duterra et al., providing service scholarship program information with other rural health program material and having applications on hand during a rural health focused informational fair increased the number of applications received.⁷ Lastly, a system of regular communication and support for program awardees has aided in the avoidance of defaults in the service program.

One limitation of this program assessment is the small number of participants that have completed training and are in full-time practice. It takes a minimum of 4 years to train a dentist and 7 years to train a physician. As seen in the results, more dentists have completed the program and continue practice. However, only a few physicians have completed all residency requirements in order to enter the workforce at the time of follow-up, disallowing for between discipline comparisons at this time. This is an area to be explored at later time-points as outcomes related to the service scholarship program continue to be reviewed for effectiveness.

Conclusion

This analysis of data available to date demonstrates the effectiveness of the scholarship program in retaining dental graduates in rural, underserved communities, following the scholarship obligation period. The authors are unable at this time to offer a similar conclusion for physicians in the scholarship program. The authors plan to continue monitoring the scholarship awardees and practice decisions and expect to report an update to this study when further data are available.