Every Wednesday afternoon, a dozen doctors-to-be walk through the Choctaw Nation Healthcare Center in Talihina — past operating rooms, registration desks and waiting areas — into a classroom. The room is filled with rows of tables. One wall holds a wooden carving of a flowing river.
The students who file in are family medicine residents, completing some of the final steps of their education that will allow them to apply for licensure, become board certified and work as a doctor in a hospital or private practice.
Talihina, with a population of less than 1,000, is a unique place for a medical residency. Most doctors go to cities for their training. There are several residency programs 150 miles to the north in Tulsa.
But, the Choctaw Nation’s Family Medicine Residency Program’s location is intentional. Doctors who train in Talihina prepare to serve patients in the Choctaw Nation and address a problem that program director Dr. Ashton Clayborn has been familiar with since childhood: Oklahoma’s rural physician shortage.
“I saw it continue through medical school and specifically living within the borders of Choctaw Nation,” Clayborn said. “Even though I was not a tribal member, I would hear about situations where they would find a doctor, but then that doctor would move along for another opportunity, or there would simply not be a physician at a clinic for a while.”
There aren’t enough doctors in rural Oklahoma to meet patients’ needs. In fact, the majority of Oklahoma’s 77 counties are designated as Primary Care Health Professional Shortage Areas by the Oklahoma State Department of Health.
“That was exactly the shortage that the Choctaw Nation tried to address by creating a medical residency education program,” Clayborn said.
Origins of the rural physician shortage
The rural physician shortage is not unique to Oklahoma, and it's not new.
Melissa Thomasson is an economics professor at Miami University in Ohio, who researched historic origins of the rural physician shortage.
The story begins around 1910 with a report made by a man named Abraham Flexner.
“He apparently went to all these medical schools, there were well over a hundred, and he wrote down what he saw,” Thomasson said.
Unlike today, when doctors need nearly a decade of formal education to practice medicine, during Flexner's time, they only needed two, six-month terms of training.
“Basically anybody could be a doctor,” Thomasson said.
Flexner’s report supported already-occurring medical education reforms in the U.S., like the embrace of germ theory and use of European-influenced clinical and experimental research.
Some schools closed. Standards for admission and the cost of medical education increased. And, so did barriers for people who wanted to be doctors – especially women, Black people, and what Thomasson calls “country boys.”
Hospital-based care and training also became central in the medical landscape.
“Doctors followed hospitals into urban areas,” Thomasson said. “They were really attracted to urban areas, we think because of the availability of hospitals. Even doctors who were born in rural areas were more attracted to urban areas.”
Twentieth-century reforms to medical education reduced opportunities for aspiring rural doctors to train and practice where they were from.
Rural training to rural practice
Today, medical schools, like Oklahoma State University’s College of Osteopathic Medicine, continue to adapt the way they approach education.
“Our institution became very focused on the rural physician shortage,” said Denna Wheeler, Executive Director of the Center for Rural Health at OSU. “About a decade ago, we started some intentional programming.”
OSU’s Center for Health Sciences developed a rural medical track. It offers clinical training in less-populated parts of Oklahoma and recruits students from rural places. OSU has also partnered to establish rural residency sites scattered throughout the state.
That’s all to train more physicians to practice where few are now.
Well over 75% of the physicians that are training in rural residencies are staying in rural areas, Wheeler said. For OSU graduates, that number is higher. About 90% stay.
Dr. Ashton Clayborn knows. She always wanted to remain in Oklahoma and practice in a rural part of the state.
“It wasn't until I got to residency and entered this rural residency that I realized, wow, I could become an academic physician, I could participate in medical education, but do it in a tiny little town like Talihina,” Clayborn said.
In Talihina, the twelve medical residents are currently training to be the next generation of family physicians to serve patients in rural Oklahoma and in the Choctaw Nation.
And, Clayborn hopes they will stay, combating the rural physician shortage a few doctors at a time.
“We grow our own,” she said.
