CoverLetter:

LhadzeBosiljevac
ProfessorLarsen
English120
Spring2015
4/1/15

RhetoricalSituation:

InthispieceforMWA#1,Iamwritingonbehalfoftheshortageofdoctorsneededinruralhealth
programs.IhavetakensomeaspectsofLSA#1andcorrelateditwithLSA#2toarguefor
medicalstudentsinNewMexicototaketheirgraduateknowledgeandapplyforruralresidency.
Iwrotemypiecein3rdperson/webecauseIwantedtoshowthatIwasnotanauthorityonthe
subjectlikeanM.D.,butwasapremedicalstudentinthepositionofarguingmypointforother
studentstojoinme.Mymaingoalinthiscollaborativewritingsegmentwastoallowmyreaders
andpeoplewhodidnotseeanissuebeforetonownoticeandfindwaysofaddressingthis
shortageofdoctors.ThesechoiceswereduetothefactthatmanystudentsItalktoabout
becomingamedicaldoctorsimplystatetheywantmoneyortheirparentsmadethem.Nothing
aboutwherelocationsneedingdoctorsaregoingthroughofhowtoimprovethelifestyleoflower
endcommunities.InmypaperIaddressthreemainpoints:
1. Bringingawarenesstotheissueofmoneyformedicalstudentsandhowruraltrainingcan
payoffloansandprovidelongtermjobsecurity.
2. AddressingtheissuethatPAsandNPsarenotabletoreallydothejobofadoctorand
shouldnotbereplacedwithbutworkalongsideallmembersoftheteamtoprovide
preventativeandsustainablecare.
3. HighlightingthenumberofstudentswhodoresidencyelsewherewhileNewMexicoisin
direneedofdoctorswhoknowthestateandcanprovidecarelongtermandbereliable
thusprovidingbenefitstothosewhodoso.

TheprocessformewentalrightexceptforthefactatcertaintimesIwouldlosetrackofwhat
Iwouldbetryingtosayandhavetorereadmysentence3or4timesbeforerealizingthatIwould
havetogoandrewordit.Althoughmyideaoriginallystemmedfrommypassioninthemedical
care,especiallyruralitissomethingthatmeasastudentfromCaliforniacannothaveeasy
accesstoo.BecauseIamnotaresidentnorwenttoschoolhere,themedicalschoolsfavor
studentswhohavelivedhereallowingmoreopportunities.Unfortunately,manypeoplewholive
hererefusetojointheseresidencyprogramsbecausetheywishtoleaveNewMexicoandwantto
studysomeplacebetter.Asopposedtomewhosacrificedeverythingbackhometocomehere

andworkintheseruralsettingswithasmallchanceofgettingin.Soforme,Iwantmywritingto
reachouttomedicalschoolstorealizeIamwillinglychoosingthisroutetohelppeopleinrural
situationsregardlessofmoneyandeconomicstatus.Whilewritingthispaper,IrealizedIcould
domoreresearchandapplymywritingskillstoapplyforruralinternshipswhichwasthe
positivepart.ThenegativewasthatwhiledoingmostofmyworkIrealizedIhavemany
obstaclestoovercomeinpresentinghowIwantmyreaderstoviewmypaperandmyperspective
asanoutsidertoNewMexico.MybiggestsurprisewaswhenIfoundout153ruraljobpositions
wereopenandthoughttomyself,Whoonearthwouldignorethismuchspace?.Theseare
opportunitiesmanypeoplewouldlovetohaveandstudentsbeingpickyaboutbeingoutfaraway
fromacitywasmoreorlessabadexcuseinmybooks.

IwasabletoutilizemySLObyworkingwithGoogleDocsinpairswithmembersoftheclassas
wellasdoingresearchaheadoftimeifIfoundatopicIcoulduseinmynextargumentor
analyticalpiece.Byworkingdiligentlyinfindingresearch,changingtopicifnecessarysoIdid
notforceafalseargumenttheseareallwaysIworkedtoreallychallengemyselfandgetoutof
mycomfortzone.Outsideofclass,IhavenowaskedmydadtohelpmejoinhisEngineers
WithoutBordersteamtoworkonwaterreservoirsonNavajoterritorytoimprovesanitation
conditionssoIcanhaveaninsiderapproachtothecivilengineeringworldaswell.

TomyreadersIaskwouldtheynowbeconvincedthattheycouldbeprovokedtohelpinrural
situations?Mymainfocusforanyonewhocomesacrossthisworkisthattheyrealizehowmuch
Iwanttoadvocateforruralhealthcareandthattheyrespectmypositionaswellaspossible.My
mainsourceoffeedbackIwouldlikeisthesetupofmyanalysisandhowmyarguments
correlatewithmyfacts.

Thankyou!

Sincerely,

LhadzeBosiljevac


LhadzeBosiljevac
English120
ProfessorLarsen
Spring2015
4/1/15
NewMexico:RuralHealthNeedsDoctors

Onthespectrumofthemedicalfieldtoday,ouroldergenerationofruraldoctorsare
retiringandthereisagapofagenerationwhowillnotfollowontosustainthechangesmadein
thesedelicatecommunities.NewMexicobeingoneofthemanystateswithahighrateofNative
andHispaniccommunitiesisolatedfromurbanlife,ithasbeenknowntobeshortonprimary
doctorsandfacechallengesmanycitydwellerswouldnotfathom.Intheschemeofthings,there
isthepersistentupheavalofnewermedicalstudentsrefrainingfromcooperatingwithanytypeof
ruralsituations.Alternatively,toincreasethenumberofdoctorsperruraldivision,prospecting
recentlygraduatedmedicalstudentstopracticeresidencyinthesesettingsbyprolongingtheir
chancestostayandovertimebuildingawellstandingnetworkofwellpayingjobsintime
solidifyingtheruralmedicinenetwork.

Consequently,thenumberofruraldoctorshasbeenstagnantintheyearsduetoalargesum
ofmedicalstudentsmovingtootherstatesorpracticinginurbansettingsintermsofresidency.
InanarticlewrittenbyOlivierUyttebrouckfromtheAlbuquerqueJournal,hesupportsthis
claimbysaying,

Thestateneedstobetterrecruitandretainprimarycarephysiciansinrural
areasbyexpandingfinancialincentives,inparticular,repaymentofcollegeloansforphysicians
whopracticeinruralareas,thereportsaid.
Manymedicalstudentsfacetheissueofhavingto
paybackalmostaquarterofamilliondollarsoffeestolargescaleuniversitiesthattakethe
money.Manypeopleassumeonceyoubecomeadoctorallpaymentsbecomepocketchangeand
thereisextramoneyinvolvedthatissimplyforspendingwhichisnotalwaysthecase.Medical
doctorsusuallychoosetheurbanroutetothinkthattherewillbemorepayforlessworkandina
waythatcanbetrueduetotheirspecialtyandneed.Butthetruthisinthecaseofworkingina
ruralsetting,aprimaryphysicianorspecialistcanbepaidmoreduetotheneedandlevelof
assistancetheycanprovidetoapatientinasettingwherealmosteveryoneisdeprivedofbasic
care.Onaverage,mostdoctorsinthesecasesarepaid$170,000asopposedtourbanpractitioners
whoreceive$161,000disregardingaidthatalreadypaidofftheirmedicalschoolfees
(
Reschovsky,JamesD.
).Thetruthisruralmedicinehasfoundavarianceofexcusesfornew
practitionerstoavoidsacrificingaconvenientlifeinanurbansettingratherthanreallypracticing

thegiftofmedicineforruralcitizens.CurrentlymanyprogramsincorrelationwithIndianHealth
ServicesandpublicsafetynetworksthatprovidemanywaysfornewGPs(generalpractitioners)
topayoffloansandgivebacktothoseinneedintimesustaininggoodhealthcarepracticesand
removingdebt(IHS).TheseidealsarealreadyinpracticewithUNMsBA/MDprogramtoadd
moredoctorstothesmallnetworkandallowinginconjunctionwiththeIndianHealthServices
ofNewMexicotoprovidelongtermjobsthatsendapositivemessageandreferraltomedical
studentshereinthestate.Dr.JonAndazolawhoisquotedin
NewMexicoInDepth
states
,
Theresalsogooddatathatshowwhereaphysicianfinisheshistrainingiswherehesmore
likelytopractice,soweofferruralexperiences,.
Thisistruebecauseoncearesidencystudent
hasdevelopedastrongconnectiontohis/herstaffandsettledtheirlivingarrangement,whichin
manyoftheseprogramstheyarealreadycovered,theirenvironmentbecomesthenormand
allowsthemtobeflexibletosituationstheyhavenocontrolover.Inruralsettings,manyofthe
patientswillalwaysbetherecreatingmoreandmoregenerationswhichmeansthesedoctorsalso
willhavethechancetoknowfamilyhistoryofmedicalissues,understandinghowtowork
arounddifferentculturesandtoreallyapplyrealworldsituationsthataprivateclinicinsome
largescalecitycannotprovide.Anumberofurbandoctorsfocussolelyonmonetaryvaluethat
theyarenevercooperatingwithpatientsandgivingonetoonecarewhichpatientsarepaying
for.Thesepaybackprogramsinplacetohelpnewlygraduatedmedicalstudentsprovidesadoor
tocreatingamatrixofcaringstaffwhoaregenuinelyopentocareandsustainingarelationship
thatgoesfarbeyondwhatmoneycanpayfor.

Asbeennotedbeforeinmanymindsofupcomingdoctorsandpractitionersalikeinthe
globallytransmutingworldofhealthandpublicsafetyistheargumentthatthereareenough
nurses,PAsandRNstocoverthemedicaldoctorsreducingtheiramount.Ofcourse,this
statementislogicalinthatNewMexicoisoneofthefewstateswhereanMDdoesnotneedto
diagnoseapatient
(NCSL).ThismeansanurseorPAcoulddothesamejob,butinthecaseof
workandhowmucheachmedicalspecialistcando,adoctorstillhasmoreflexibilityandsayfor
whatneedstobedoneincludingwhatfollowthroughsareneededinthecaseofmedicineor
surgery.Aphysiciansassistantwillspend2yearsafterundergraduatestudyingwhileadoctor
canspendupto6yearsinschoollearningthecomplexindepthdetailoftheirpractice.Underthe
guidanceofadoctor,thePAwilltakeordersandassistsinclinicalwork.Conversely,inthe
severityofruralsituations,theneedfordoctorsallowsmoresurgicalhandsonlaborthatanurse
orPAarenotlicensedtoperform(SophieCresswell).Ofcoursenursescanruntheirown
practicesandsuchbutagain,ifanysituationofsurgicalormorespecificneedswererequired
theywouldnotbeabletohandlethecasenorhavethecapacitytodoso.AspredictedbyM.D.s
JohnW.DenhamandC.GlennPickardJr.intheirbook
ClinicalRolesinRuralHealth
Centers
,theyoverallsummarizethegeneraltypesofnonphysicianprovidersandexplainthat
theywillbecomethenewfaceofthehealthpractitionerworld.Thiswaswrittenbackin1979

andnowin2015thehypothesiswasinfactcorrect.Butstill,ithasnotlimitedtheneedfor
doctorsandnordoeshesaythatdoctorswillbecomeuselessbuthavemorerolesworkalong
sidewithinconjunction.JonM.Bailey,fromtheCenterforRuralAffairsexplains
Therural
dependenceonprimarycarephysiciansisamajorlongtermconcern.
,inwhichmanydoctors
arenotstayingorpositionsbeingfilledbynursesandPAsaresimplynotcuttingitfortheneeds
ofthecircumstances.This,inshort,createsanissueofnotasolidstandingpracticeofMDs,
PAs,Surgeons,etc.,toprovidethecarenecessary.Cuttingthespendingcostsontheamountof
doctorsmightsoundlikealogicalideauntilitbackfirestothepointwheremoneyiswastedon
carethatwasnotproperlyadministeredfromthestart.Ifyouweregoingtobehavingsurgeryon
abrokenbonethathasbrokentheskinssurfaceyouwouldwantanorthopedicsurgeonanda
staffofmedicaldoctorsratherthananursepractitioner,correct?Andashortageofgood
specialistswouldmeanhavingtotravelforhourstofindonewheninthosecasespersistent
bleedingcouldmeandeathleftuntreated.ButbyhavinganumberofM.D.sandspecialiststo
providereferencetoallowsforpreventativecareinNewMexicoandstatesalikewhohavethe
issueofnursesbecomingprimaryphysicianswhichcanbeariskyoperation.Theprimarygoalof
ruralcareistoimplementsafeandefficientlegalpracticesofmedicinethatneedstobedone
withanequalteamofdoctorsandnursesalikenotanunbalancedratio.

AnotherissueisthatmedicalstudentswhograduatefromUNMdonotretaintheirresidency
here.AgaininreferencetoDr.Andazolahestatesthatonly79%ofstudentsattendingmed
schoolstayinNewMexicowhichinturnhurtsnotonlythestatebuttheeconomyanditsrural
counterpartsaswell.Althoughmanyarguethatotherstatesprovidebetterpayandmorestable
jobopportunitiesthisisnotalwaysthecase.Insituationsthatareindesperateneedofruralcare
thatiswherejobopportunitiesarise.Uyttebrouckstatesthat153primaryphysiciansneedtobe
addedtotherurallatticetomeetthenationalaverage.Thismeansthatforthestudentswhoare
competingforthealreadydenseseniorpositionsofurbanhospitalswhomayormaynothave
timefortrainingthattheymighthaveabetterchanceofretainingajobthatnotonlypaysoff
theirloanbutgivesthemextensivetrainingbygivingback.Thesearegreatprogramsthat
medicalstudentsshouldgivethoughttoandunderstandthatatwoyearsacrificecouldmake
majorchangestoasmallcommunity.

Itcanonlybethroughtimethatthenumberofdoctorswhowishtopracticemedicinewill
choosetheroutetogoruralinwhichtherecanbeawidespreadchangeintheparadigm.There
aremanymorebenefitstobeingahealthcarephysiciantograduatestudentswhowishtopayoff
loansandapplytheirmedicalknowledgeforthosewillingtoacceptit.Althoughmoneyandthe
needtodoctorsinthesescenarioscanbecomplicatedandhardtocomeacross,thechanges
studentsinthemedicalworlddecideupongeneratesaflexibleandunderstandingsetofskills
thatcanbeappliedfortherestoftheircareers.Therearemanyopenjobsintheserural

communitiesbecausethecareisneededtodaytochangetomorrow.Byallowingthesestudents
toknowwhattheycandotoopentheseopportunities,therecanbeawellbalancedratioofurban
andruraldoctorssettingouttopracticewhattheyintendedtoprovide.

WorksCited:

Bailey,JonM."Top10RuralIssuesforHealthCareReform."
ASeriesExaminingHealthCare
IssuesInRuralAmerica
(2009):n.pag.CenterForRuralAffairs,Mar.2009.Web.30Mar.
2015.<http://files.cfra.org/pdf/TenRuralIssuesforHealthCareReform.pdf>.

Busemeyer,Deborah."DoctorShortageForcesNMtoThinkCreatively."
NewMexicoInDepth
.
InvestigativeNewsNetwork,06Jan.2013.Web.30Mar.2015.
<
http://nmindepth.com/2013/01/06/doctorshortageforcesnmtothinkcreatively/
>.

Cresswell,Sophie."WhatIstheDifferencebetweena
DOCTOR
andaPhysiciansAssistant?"
GapMedics
.N.p.,n.d.Web.30Mar.2015.
<
http://www.gapmedics.com/blog/2013/10/16/thedifferencebetweenadoctorandaphysicians
assistant
>.

Denham,JohnW.M.D.,Pickard,C.GlennJr.M.D.,
ClinicalRolesinRuralHealthCenters.
ChapelHill,1979.Print.30Mar.2015.

"IndianHealthServiceTheFederalHealthProgramforAmericanIndiansandAlaskaNatives."
LoanRepaymentProgram
.DepartmentofHealthandHumanServices,n.d.Web.30Mar.2015.
<
http://www.ihs.gov/loanrepayment/
>.

Reschovsky,JamesD.,Staiti,Andrea."CenterforStudyingHealthSystemChange."
IssueBrief
No.92
.CenterForStudyingHealthSystemChange,Jan.2005.Web.30Mar.2015.
<
http://www.hschange.com/CONTENT/725/
>.

Uyttebrouck,Olivier."NMRuralAreasSufferSevere
DOCTOR
Shortages."
ABQJournal
Online
.AlbuquerqueJournal,28Oct.2014.Web.30Mar.2015.
<
http://www.abqjournal.com/487352/biz/nmruralareassufferseveredoctorshortages.html
>.