Community-Driven Medical Education: The Rural Component

Robert C. Bowman, M.D.   [email protected]

The words "Country Doctor" call up memories of horse and buggy, black bag, and devoted, tireless servants. These physicians have long earned the respect and admiration of a grateful nation. What is almost forgotten is that rural physicians once commanded the same respect from contemporary medical school deans and experts in medical education, even such notables as Sir William Osler and Abraham Flexner. But the tide and times have changed, Marcus Welby has been replaced by ER’s Mark Green, and few if any of the nation’s most educated students, faculty, and leaders understand this purest form of primary care.

Today’s rural physicians have had better training than ever before. This training has not changed the attitudes of some academic faculty who continue to look down upon small town physicians. Students are not immune to the attitudes of such faculty. By the senior year of medical school, only 400 students out of over 16,000 remain interested in practicing in towns of less than 10,000 people (AAMC GQ 1995 Rural Interested Students). Medical leaders, facing regular criticism for failure to graduate physicians for underserved areas, deflect the blame by citing the poor rural economy and "a paucity of satisfying cultural and civic outlets" to attract graduates (Cohen editorial Dec 1998 Why Doctor's Don't Go.  For such highly educated and respected people with enlightened attitudes toward tolerance and understanding this is difficult to comprehend. The only plausible explanation for their attitude is lack of contact with rural communities and peoples. In more recent years the same medical leaders have seen the need to admit students for more than just intellectual criteria. Cohen Encourages Admissions to Look Beyond MCAT )

Students continue in the pipeline to rural practice despite adverse selection policies, a discouraging environment, and a "paucity" of career-specific preparation. Students interested in rural practice were twice as likely to know this career choice at matriculation as other medical students. (AAMC GQ 1995 Rural Interested Students). Their solidarity is matched by rural medical educators who remain committed to preparing them for the medical, social, and economic challenges they will face. A few medical schools and residency programs hold course even when facing unreasonable demands by accrediting bodies. Rural physicians give ever more to the cause by sustaining current services in their rural communities and by preceptoring the students and residents who will serve their community for generations to come The Role of the Rural Community and Practitioner. Students see the inequities and hear the complaints, but hopefully enough experience the following:

The final component is supportive medical leadership. Sometimes this is mandated by legislative actions and approaches  and at other times visionary leaders step up and take the time to visit and interact with rural physicians and rural communities and are in a good position to reach out in service. Most often there is procrastination until great times of crisis:

Clearly the time of crises is here and it is time for the right thing to be done.

"I operate from a perspective -- a belief, a feeling -- that the more I can understand where other people are coming from and what they value, the more I can trust them and they can feel comfortable with me. In essence, the more we mutually trust each other, the more we really understand each other -- that is the key to making things happen." Don Weston, Vice-Chancellor of Health Sciences in West Virginia http://www.uic.edu/sph/healthleaders/mainstories_Weston.htm

The Best Approach

The nation has known this for decades: 

Health professionals education represents one of the South's major successes….. despite increases in the overall supply ….. serious problems of distribution of professionals to geographic, subspecialty, and public service areas of need continue, except for those situations in which carefully coordinated strategies have been directed to specific problems.       Southern Regional Education Board 1983

“In order to increase the numbers and quality of rural doctors it is necessary to implement a series of strategies aimed at establishing an integrated career pathway of education and training for rural practice." -WONCA Policy on Training for Rural Practice 1995

While the existing array of strategies is better than doing nothing, it has not prevented the sharpening of rural/remote access as a policy issue. Something different and additional will have to be done in future if rural/remote access is to be improved. -Barer Stoddart 1999

The best approach to satisfy rural community needs is a community-driven approach. In this approach the needs of the underserved communities drives the process with all players working as a team.

Medical school admissions is by far the most important element. Medical schools must understand how to choose the students that are most likely to choose rural practice. Admissions should focus on students with rural background, Family Medicine interest, maturity, and service-orientation. Admit More Who Will Become Rural Physicians

Rural background and Family Medicine interest: The most extensive work in this area is by Howard Rabinowitz, M.D. He initiated the Physician Shortage Area Program (PSAP) in a most unlikely location: an urban, private medical school in Philadelphia. Rabinowitz set up a special admissions track for students in 1971. His most recent work demonstrates that 78% of the decision for rural practice involves choosing students with rural background and Family Medicine interest, characteristics available to any admission committee. PSAP students also have stayed in Pennsylvania rural locations, making up 21% of the rural family physicians in the state. (Rabinowitz Sept 2001 JAMA).

Maturity and lower socioeconomic background: Senior students interested in rural practice were older and were more likely to be married and to have children (Bowman AAMC GQ). It may be that the ability to withstand the significant socializing influences of the medical school environment is important for those with the intent to become a rural family physician (Xu et all). Students from lower socioeconomic backgrounds are more likely to choose primary care (Madison) and the AAMC reports that they are more likely to serve in underserved locations. Students interested in rural practice also expected slightly less future income (Bowman AAMC GQ) Rural Interested Students.

Service-orientation: Service Orientation It seems intuitive that those most likely to serve the underserved, would be more devoted to service. Studies bear this out. Rural interested senior students who were interested in locating in towns of less than 10,000 were twice as likely to serve as volunteers locally and overseas at each of the 4 years of medical school. They are also 6 times more likely than their peers to be interested in serving the underserved (Bowman AAMC GQ) Rural Interested Students. 

Update on Oral Roberts Medical School, see Error note

Rural medical education begins when with rural physicians in small towns. Rural doctors can facilitate a health career choice by allowing students to shadow them and encouraging promising students with advice and shadowing opportunities. Rural physicians and academic rural faculty work together serve on admissions committees and train students and residents. Rural faculty advise rural student interest group leaders to reach out to rural background students in high school and college. Rural background students often need assistance to bring applications and experiences up to the level of other applicants, similar to minority applicants or those from poorer school districts.

In some communities with chronic problems in education, economics, and health care; students with the right characteristics for service will need more assistance for a longer time with outreach activities to middle school or beyond. This allows larger numbers to attain a level of preparation so as not to risk academic failure in professional school. Pennsylvania's high ratings in these areas may have allowed Rabinowitz to get great results by working with small college advisors.

Rural physicians and faculty must work together to hold state governments and medical schools accountable. The top factor in the rural graduation rate of medical schools is the rurality of the state (Rosenblatt WAMI) Which Medical Schools Produce Rural Physicians?.. Further studies indicate that rurality is the only significant factor. A few outliers exist because of the efforts of leadership (Bowman Med Sch) Medical Schools and Rural Graduation Rates . Rural graduation rates therefore, may reflect the political pressures of the rural population. Another reason may be the nature of rural states. The true potential of rural medical education has been realized where faculty work to facilitate constant contact between students, communities, and preceptors. In rural states these key players may already know one another well.

Building a Community-Driven Medical Education system is indeed a complicated operation, but no more so that those who have pioneered innovative rural practices:

Building a community-responsive rural practice is endless work, a job that inevitably becomes as frustrating as it is rewarding. It requires a large tolerance for uncertainty and willingness to risk. One must deal effectively and tactfully with a variety of constituencies, any one of which can enhance or threaten the success of the venture. These include community people - supporters and opponents - local physicians, government officials, a hospital, one or more funding sources, a new staff and, of course, patients and their families. Not everyone is enthusiastic for the new practice or empathetic with its leaders- who are at all times expected to maintain their own idealism, energy, and optimism. New rural health centers are fragile entities, both economically and politically. When they finally succeed in becoming established it is usually because their people-leaders, staff, board members-were as stubbornly determined as they were resourceful. Donald L. Madison, 1980

The relationship or bond between a rural physician and his or her community has best been described in terms of courtship (recruitment) and marriage (retention). The marriage of rural and academic communities has created some excellent medical education models that hold the potential to graduate more rural physicians and even restore other types of young professionals to rural areas.

Shotgun Weddings Create a 84,000 Square Mile Classroom A powerful Minnesota legislator got the attention of the University of Minnesota by threatening to withhold state funding unless the medical school responded to rural needs in the state. Jack Verby used his 20 years of rural practice experience to design the Rural Physician Associate Program (RPAP). Verby articles on RPAP

Since 1971 it has involved 40 third year medical students each year, half selected from traditional Minneapolis-based students and half from the Duluth 2 year program where medical educators put a priority on rural and primary care admissions.

Medical schools will respond to the needs of rural communities, if there is leadership and commitment (and no apparent escape). - RCB

Selecting the Best, Not Just the Brightest Medical school faculty such as Howard Rabinowitz tied the offspring of rural communities to the academic community through a specialized admissions process. The impact of the PSAP program is indeed remarkable. Some feel that the small college health advisors can play a special role in connecting rural and academic communities. Small college advisors and faculty given this opportunity have done well in other states. Area Health Education Centers have also worked to feed the proper students in to admissions.

Special rural admission tracks have been successful in several medical schools.

Matchmaking is not an uncommon practice in traditional rural communities in years past. The late Robert Waldman, M.D., used his leadership abilities and position as Dean at Nebraska to initiate a hub and spoke approach known as the Rural Health Education Network. After this foundation was laid, the next step was the Rural Health Opportunities Program (RHOP) which admits rural high school students into a variety of health professions schools. In the medical school component, 4 – 6 medical school students from the smallest towns are admitted to medical school after graduation from high school. RHOP students attend one of two small rural colleges at either end of the state. These two colleges have used the program to improve their admissions and academics, making them more attractive to other rural high school students interested in a variety of professions. Other students not in RHOP are now admitted to UNMC from Chadron and Wayne State. Tom Bruce led Arkansas Arkansas Approach along a more extensive pathway involving AHEC, admissions, decentralization of medical education, and outreach placement. The state experienced a 20% increase in the physician-population ratio in a 5 year period, twice that of other states in the south and midwest. (Improving Rural Health)

Nebraska students admitted through enhanced admissions have completed family practice residency training and the graduates have entered rural practice at a rate 50% higher than only a decade before. Graduates going out in larger numbers and pairs have stabilized many rural health systems on the verge of collapse. (Stageman et all accel) Nebraska and Arkansas have clearly added workforce with a coordinated approach capped by dispersed graduate medical education.  Arkansas Approach    Nebraska

Residents in these dispersed graduate programs have added workforce to small towns and have worked to stabilized small health systems during training and after graduation.

Courtship and Marriage may be the only approach worth undertaking because of the trauma of a failed match in both graduate and rural community:  "The appalling cost to both the physician and to the rural community of this mismatch has not been well described. The young physician and his family moves to the town in good faith, making a long-term commitment. Within weeks or months it becomes apparent that the expectations of the doctor, and sometimes the town, are not to be realized. The agonizing decisions then begin whether to sever the relationship... For the rural community the trauma is almost as great: it is easier in most instances to be perennially without a physician than to find one, go through the process of change in adapting to a new one, lose the doctor and start the entire cycle over again." - Tom Bruce in Improving Rural Health

Restoring the True Potential of Medical Education – Improving Rural Education and Rural Economics When the Flexner reforms impacted medical education a century ago, they stimulated high school and college education to make great strides. Unfortunately these reforms made it more difficult to train doctors for underserved areas and minority populations (Ludmerer, Time to Heal). Medical education could reverse these unanticipated effects by working more closely with small colleges.

Rural colleges may also help to screen out rural background students desiring to escape rural areas entirely, a problem with some types of scholarship or state anti-brain-drain programs.

Programs like the Rural Health Opportunities Program that build up small colleges may lead the way to more than a cure for physician maldistribution. Small towns also need other young professionals to provide additional leadership and economic impact. Why There Are Few Young Adults in Rural America Young professionals also support and encourage and retain one another. Efforts to improve small colleges may restore the breeding grounds for these young professionals. Students doing pre-professional preparation in a rural college location are likely to marry a spouse that is more likely to return to small towns.

The RPAP program in Minnesota gives just a hint of the economic impact of programs that work to restore young professionals to rural areas. RPAP has graduated over 900 physicians since 1971 and most have gone into rural areas. RPAP costs the state about $800,000 a year, but the RPAP graduates that have chosen rural Minnesota have generated over 3 billion dollars of economic activity. Each rural physician goes a long way toward improving the rural economy. These figures stand in direct rebuttal of top medical leaders who blame the poor rural economy for physician maldistribution. The fact is that rural health is a major part of the economy, especially in rural locations (Doeksen).  By the numbers, Rural Doctors and Rural Economies

Medical Education: Workforce to Shortage Areas Rural graduate medical education with the intent to meet the needs of rural communities should be Community-Friendly. Programs and experiences should give back to communities more than they take out. For too many years institutions have taken advantage of the good nature of rural peoples and their desperate need for health care. Community Friendly Aspects

The Combined Outstate Residency Experience (CORE) in Nebraska is a two month required rural preceptorship that enhances local workforce in rural shortage areas and can stabilize rural health systems by providing much needed physician FTE. Residency programs in the state work together to assure 4 rural locations a constant stream of residents for up to 3 years. The best learning experiences are "hands-on." Not only do those interested in rural practice learn best this way, but communities learn how to practice good recruitment by having residents in their communities.

The savings in recruitment and orientation costs can be even greater in a long term medical school preceptorship or any graduate program in an underserved location where the trainee stays on to practice. Over 60 of the 900 graduates of the RPAP long term preceptorship have returned to the community where they did their rural experience. About 11% of the RMED graduates at Syracuse have done so. There is also evidence that long term preceptorships enhance the local workforce. (Jack Verby, personal) (inter elect Australia)

Full-Time Rural Workforce Through GME Robert Maudlin tied small rural communities such as Colville and Goldendale to graduate training in Family Medicine to create the first rural training track at the Spokane Family Medicine residency. This program had efficient costs, excellent training, and superb outcomes. RTT programs nationally continue to graduate 75% into rural practices. They also improve rural hospital admissions and finances (Rosenthal, RTT). Rural workforce experts such as Pathman believe that specialized graduate training may also hold the potential to improve rural retention.

Rural residency programs, rural training tracks, and rural satellite sites serve over a hundred rural communities across the nation, but there is even more potential. Some 800 of 2500 family practice faculty have been rural physicians (Bowman and Penrod) Fam Med Res Prog and Grad of RFP. Many of these might have been able to stay in their rural practices if the training had moved to their location rather than vice versa. Trainees experiencing the bond between rural practitioners and communities firsthand might well value this long after graduation.

Each level is interdependent with the others. It makes no sense for educators to create rural graduate programs if there are few or no students interested in taking advantage of them. The Nebraska rural programs do not stand alone. A former rural physician guides admissions at Nebraska. All Nebraska students do rural experiences in the first and third years. In Minnesota, the RPAP success would be much more limited without the Duluth selections process. Duluth Plus RPAP

The Ultimate Community-Driven Approach Threatened with the closure of one of the three medical schools, the West Virginia medical schools decided that they could indeed work closely with rural communities and facilities. Health professions education has moved out into rural West Virginia in a variety of disciplines and locations. Rural students introduced into the pipeline as early as middle school also enjoy tuition free college and health professions training. Perhaps this new generation of graduates will reward the West Virginia’s underserved communities with service instead of chafing at crippling debts (Partnership report at web)West Virginia Rural Health Education Partnerships . The Alabama Rural Health Alliance works through a Rural Health Scholars program to take a similar approach. 

Many rural medical education programs have been the work of one person. As such, there is always a question regarding sustainability. Sustainable programs integrate into the fabric of the state in such a way that their continued success is assured. The RPAP model has graduates are in every legislative district. RPAP students have perhaps the most extensive faculty development as this process begins when the are third year students. The preceptor network that Joe Hobbs has built at the Medical College of Georgia is a comprehensive model where preceptors are considered faculty and exchange benefits and teaching between the two communities.

Because students with the best characteristics have often had the most borderline preparation, there is always a risk of academic failure. There is some potential for accreditation problems, lower board scores, and increased resources needed from faculty or student services. Accrediting bodies may also still hold prejudice against the preceptor models dating back over 100 years. Studies have demonstrated that community-based training can be equal or better than traditional methods.

One of the most gratifying "side-effects" of choosing community-driven students is the work that they initiate to establish volunteer clinics. They also are adept at accomplishing relevant changes in curricula and procedures in medical school and residency. Faculty and medical leaders become familiar with this characteristic but it is a welcome trait when compared with the current students who whine about grades, especially on community-oriented projects.

The Rural Medical Educators Group of the National Rural Health Association (NRHA) For the latest in information on the Rural Medical Educators is current and former rural physicians who are driven to connect medical education to rural communities. Without devoted rural medical educators with the time and support to do their work, it is likely that fewer students will consider careers in rural practice. Rural medical educators continue traditions and values such as the importance of personal contact. Personal contact is clearly the major mode of replication of RME. Jack Verby's sabbatical to Syracuse resulted in the first replication of RPAP. Maudlin's activities at meetings and contacts with faculty had similar results for RTT programs. The Minifellows at East Tennessee supported one another, developed programs, initiated strategies, and trained each other for leadership positions that were retained in rural medical education. Minnesota RPAP preceptors pass their knowledge and experiences along to successive generations.

The community-driven approach is not as complex as it seems. It does not really add original ideas or programs. The beauty in the approach is that it restores proper relationships, incentives, and emphasis. States did not know that their efforts to centralize education would destroy the small college breeding grounds of all young professionals. Nor did they know how easy and efficiently a reversal of this process would work. The nation clearly does not understand how it has worked to retard the education of its physicians and how it forces medical schools and physicians away from the primary care and underserved locations. Restrictive laws, federal and state audits, bad incentives, a crushing liability climate, and poorly thought out programs to reduce medical costs are significant barriers. Medical education that selects for rural-interested candidates with maturity and determination can overcome these barriers and even more.

This article is about service. Our nation needs serving people to become students so that they can graduate and serve rural communities. Community-driven models of service have some unique characteristics. In such an approach it is difficult to determine who or what is responsible for the success of the program, because so many have contributed in so many ways. Service is a common ground beyond the rhetoric of disciplines or schools. In Nebraska it is refreshing to have conversations with program directors in a number of locations, discuss admissions of physician assistants, talk grant programs with family nurse practitioner faculty, and work on teaching programs with physicians in other departments. Even though there is some competition, the real goal is service to rural communities, and as such there is less emphasis on efforts where one wins at the expense of another.

Rural health systems that have survived and thrived in recent years have already discovered many of the same principles. Successful rural health systems have learned not to depend on federal or state programs. They know that the answer is better working relationships between boards, administrators, physicians, nurses, patients, and community members. It is time for academic health centers to learn the same lessons by working more closely with rural and underserved communities so that they can continue to serve.

1. Admissions of students with rural background, Family Medicine interest, maturity, and service-orientation: Students should clearly have a passion for rural communities rather than desiring to escape them;  Admissions Package
2. A Comprehensive Community-Driven Approach For Medical Education For the Underserved: The correct approach will encompass the 10,000 square mile statewide classroom envisioned by Jack Verby (Verby JE Physician Redistribution in Minnesota and the 84,000 square mile classroom Minnesota Medicine Vol 68, October 1985 p 757) see also Community Driven Approach
3. Constant contact with rural communities, rural faculty, and rural concepts: Students stay connected to rural communities through experiences (especially long term) and faculty and students bridge any gaps between rural and academic communities.
4. Specific Rural Graduate Training In and For Rural Locations: The accelerated rural training model needs to be expanded beyond a single program for further study. Rural and inner city medical education programs serving the underserved need a direct funding line from the federal government that is linked to safety net resources and clinics; Choices in Graduate Programs
5. Strong rural practices and rural health systems that will continue to support current and future rural physicians and pursue quality rural health care;
6. Support for rural medical education efforts and faculty that facilitate the above;
7. Leadership that supports and encourages the above at medical schools, in state government, through associations, and at the federal level. Rural family physicians will need to step up in their positions of leadership in Family Medicine.

Robert C. Bowman, M.D, Co-Chairman

Rural Medical Educators Group of the National Rural Health Association

UNMC Department of Family Medicine Director of Rural Health Education and Research

983075 Nebraska Medical Center

Omaha, NE 68198-3075

(402) 559-8873 or fax at -8118

Email: [email protected]

http://www.unmc.edu/Community/ruralmeded/

Outline

Why have medical schools failed to meet the needs of underserved communities after decades of effort and billions of state and federal dollars?   

The Environment  Changes  Lack of Leadership  Lack of contact

• Shotgun Weddings Create a 10,000 Square Mile Classroom
• Selecting the Best, Not Just the Brightest
• Matchmaking
• Restoring the True Potential of Medical Education – Improving Rural Education and Rural EconomicsMedical Education: Workforce to Shortage Areas
• Full-Time Rural Workforce Through GME