BOZEMAN — A paper published this week in the New England Journal of Medicine examines the aging physician workforce in rural areas — a demographic shift with important implications for the future — and offers strategies to forestall the resultant, projected diminishment in access to health care.

The paper’s lead author is Lucy Skinner, a student at Dartmouth College’s Geisel School of Medicine. Co-authors include Montana State University College of Nursing professor Peter Buerhaus, Doug Staiger at Dartmouth and David Auerbach, external adjunct faculty at MSU.

“With close mentorship and support from Drs. Buerhaus, Staiger and Auerbach, I used an analytical model that they developed to predict nursing workforce issues to forecast urban and rural physician supply through 2030,” Skinner said.

The researchers found that while the total number of rural physicians has been stable over the past 20 years, the rural physician workforce is aging. By 2017 more than half of rural physicians were at least 50 years old, and more than 25% were at least 60 years old.

Skinner said this demographic shift forecasts a troubling future with increasing health care disparity. Rural residents who are likely to be older, poorer, more commonly uninsured and have lower life expectancy will have limited access to physicians, which may reduce preventive care and further exacerbate unmet needs.

“The implication of this is that the supply of physicians in rural areas is going to decline in the next 10 years by 23% as older physicians retire and are not being replaced by younger physicians,” Skinner said. “As a result, if nothing is done, the already large disparity in access to physicians between rural and urban populations is going to widen.”

The researchers acknowledge that initiatives involving focused training for medical students likely to practice in underserved rural communities have slowed the decline in the number of rural physicians, but those initiatives are unlikely to narrow the care delivery gaps. They added that the greater the shortfall in the rural physician workforce, the harder it may be to attract younger physicians who will need to assume a higher patient workload.

To break this cycle of decline, the researchers offer additional strategies, including expanding graduate medical education programs in rural hospitals, increasing access to care through mobile health vans equipped with medical technology, and widening the adoption of telehealth services.

They also suggest the rapidly growing nurse practitioner workforce could be part of a solution to narrow gaps in health care delivery. A high percentage of nurse practitioner training is in primary care and rural medicine — higher than that of physicians. And a growing body of evidence confirms “the high quality and cost-effectiveness of care provided by nurse practitioners and their greater propensity to serve vulnerable populations.”

Skinner, a second-year medical student, first became interested in rural medicine while working at MSU in the College of Nursing. Skinner, who plans on practicing rural medicine, said, “I am drawn to small, tight-knit communities and to the variety and full-spectrum of care that comes with rural practice.”

The paper is online at https://www.nejm.org/doi/full/10.1056/NEJMp1900808?query=featured_home.