INTRODUCTION Rural America is desperate for physicians. Lack of physicians is a factor in access to health care, in rural hospital closure, and in the loss of jobs in rural areas. For years Family Practice and non-physician providers have clamored for training funds based on the needs of rural America yet the demand still exceeds the supply. Even osteopathic medicine, once a bastion of primary care, faces the challenges of subspecialization that our distorted reimbursement system inflames.
Rural health education is in an infancy stage. The past one hundred years have seen the rise of American medicine to unprecedented heights. Paradoxically access to basic health care for rural people has worsened. The creation of Family Practice offerred an opportunity for new approaches to rural health, but underfunding and a diseased health care system continue to crippled the rural outreach branch of Family Practice.
Research in rural manpower shows little advance from that of twenty years ago. What is known about producing rural physicians is not applied by admissions committees and program planners. Studies of the value of rural preceptorships reveal conflicting results. More is surmised about why physicians leave practice than is known about why they choose rural practice and stay. Almost all of these studies are retrospective, occuring years after the experiences. These studies also focused on the participant, but not the curriculum, location, preceptor, faculty, or spouse. Even the best rural experiences face a problem: trainees must eventually return to urban locations to complete training. Only a few medical schools and residencies are in towns of less than 50,000 and few have any true commitment to the needs of rural America. Band-Aid approaches to rural health have not worked.
A comprehensive approach is necessary in order to address the nation's need for rural providers. The solutions will be complex. They lie beyond the scope of any one institution or state or organization or community. The solutions will involve rural communities and their young people, health educators and their institutions, and leaders at all levels.
FOUNDATIONS OF EFFECTIVE RURAL PROGRAMS
INSTITUTIONAL COMMITMENT Rural program directors must obtain the support necessary to establish rural programs. This commitment must be reflected in the support from the state, the regents, the dean, the hospitals, the medical staff, the chairmen, and other program directors. In these times of difficult state budgets, new or different programs like rural are likely to face big cuts or termination without strong support on all levels. Smaller medical schools may not be able to support multiple missions. They may need to stay focused only on rural primary care. Departments can be enticed into multiple areas of service, teaching, or research. Small departments or programs who wish to do rural programs may need to focus in this area or work in consortia.
PRIORITY FOR ADMISSION OF POTENTIAL RURAL PHYSICIANS It is a great waste to prepare rural and primary care programs for students who are heading for subspecialty medicine. Medical school applications are up, but this is no guarantee of primary care or rural practice interest. It is unlikely that the trend toward fewer rural background candidates will be reversed in most states. Increasing the numbers of students going to medical school has not produced large numbers of rural physicians. State governments expect more rural physician production for the tax dollars they contribute.
Studies of the decision for rural practice in students and family practice residents highlight the importance of a rural background for the trainee and his or her spouse. Those attending state colleges are more likely to choose primary care. Trainees from professional or higher income families are less likely to choose primary care and rural. Those with hunting and fishing as recreational activities are more likely rural doctors. Those with the highest MCAT scores are less likely to choose rural. Those with higher academic performance are more likely to feel isolated in non-metro settings. With most medical schools competing for the best and brightest, primary care and rural candidates may be left behind.
LOCATION OF THE TRAINING The rurality of the medical school or residency location may be a key factor. East Carolina, East Tennessee State, and other schools in more "rural" locations have higher primary care productions. Medical schools such as Duluth, Michigan's Upper Peninsula program, and South Dakota (now four year) with two years of training in a more rural location have some of the highest rates of primary care and rural physician production. Most large urban medical schools have very little interest in rural programs. Those who attend the more rural schools may have more interest in staying rural. Among the residencies, family practice graduates tend to locate near their residency programs and have by far the most rural locations.
THE MEDICAL SCHOOL ENVIRONMENT is important. Being urban and socializing the students is bad enough, but the subspecialty prejudice of most medical schools is worse. The environment must change such that the most respected career pathway is that of the primary care physician. In many states the model should be the rural primary care physician. This pathway should be an expectation. With the exception of psychiatry and some need for general surgeons, the nation needs few other types of physicians.
The institutional mission, curriculum, departments, chairmen, faculty, and residents must all be a part of this environment. Those who plan rural health careers must be supported, not discouraged. In the likely case that the environment is not conducive to rural choices, a Family Practice or Rural Student Interest Group may be helpful. These groups identifies students with family practice or rural interest as early as possible. These students meet with each other, with rural faculty, and with rural preceptors in the first two years for information and support. They obtain information about rural experiences, receive realistic and practical information on rural practice, and access faculty for career counseling.
A STRONG, RURAL-ORIENTED FAMILY MEDICINE DEPARTMENT OR PROGRAM Family medicine departments often take the leadership role in medical schools when it comes to developing rural programs and curricula. Often the chairman or key faculty have been in rural practice and have seen the totality of primary care that rural practice offers. They have felt the need of rural communities first hand and have worked with rural organizations, state departments, or family practice organizations on the rural health effort.
A chair must be realistic, however. Departments must have adequate funding. Because of the multiplicity of roles and challenges for academic medicine, meeting the need for rural physicians can drift further down a department's priority list without a strong mission and leadership. Legislative efforts are often an important component of this support. Funding from states and granting agencies is changing and there are more opportunities and challenges for family practice than ever before. Departments must be able to meet the needs of the medical school in training all students in primary care as well as recruit and train quality residents. They must have adequate faculty to do this. Once this baseline is established, rural programs development can begin.
ACHIEVING CRITICAL MASS In order to lay the foundation for rural programs, one must maintain current programs and obtain the personnel necessary to establish a new program. This involves meetings (at all levels), correspondence, grant writing, documentation, recruitment, and lots of planning. A rural team is essential. An isolated single rural faculty member can become as overwhelmed as a solo rural physician in a shortage area. The members of the team need to contribute a multitude of necessary talents including networking skills, administration, evaluation strategy, and funding abilities in addition to the standard practice and education efforts. Effective rural programs take part and full time rural faculty, a dedicated group of staff, a supportive administration, and input from trainees. Often a strong family practice department or a larger community-based program, working with a hospital and other departments and leaders, can effect this critical mass.
RURAL TRAINING DURING RESIDENCY Residency programs can get very busy. The accreditation requirements can challenge those who develop rural programs. Residents can complain about the travel and time away from family that rural rotations can mean. Access to rural experiences, meetings, committees, and advisors should be a priority. Curricula should address rural experiences, practice management, information access, procedural needs, and the need to recognize that there are a tremendous variety of rural practices and communities available.
LOCAL SUPPORT Support from rural communities is important. Nothing can terminate a training program faster than failure to work with a community. This can be difficult as academic institutions have a poor history of cooperation. This is especially true in rural health. Assistance from the primary training hospitals is important also. Building rural programs takes a lot of time and effort working one on one with key individuals and meeting with the leaders of the community, the hospital, and the health professions.
SUPPORT FROM STATE GOVERNMENT AND RURAL ORGANIZATIONS IN THE STATE This is often a measure of the rurality of the state. Efforts to produce rural physicians can fail miserably if the state does not support current rural physicians with adequate reimbursement and practice incentives. The state should take advantage of the residents that it is training by recruiting them heavily throughout their residency. Rural organizations offer important assistance in developing rural programs. They can often share resources and facilitate funding efforts. When the need for rural programs is challenged, support from a state rural health organization, an Office of Rural Health, a Primary Care Association, and the state medical associations is crucial. Departments of health can also be major contributors to rural health efforts.
EXAMPLES OF RURAL TRAINING AT ALL LEVELS
PREPARATION FOR MEDICAL CAREERS Some states are blessed with excellent education to rural areas. Others lack such quality. The numbers of rural background students steadily dip each year. Education and orientation to college is part of this. Experience and interest in health careers is another. Kentucky's PEPP program began in 1971 to identify high school students from underserved areas who had an interest in health careers. Counselors gave advice on admissions and courses and testing. Students attended seminars and received a higher priority score for admission to medical school. Graduates of the program do as well as other students and choose primary care at a rate far above the national average.
ETSU's Rural Health Career Fair brings rural high school students from underserved areas to the campus of ETSU to examine different health careers. They spend time with students and faculty in Medicine, Nursing, and Allied Health. They see interesting demonstrations (such as heart and lung anatomy) and attend presentations by the many health disciplines. They discuss obstacles to their choice of a rural health profession. Students and faculty discuss ways to bypass these obstacles, including scholarships, special counseling and academic preparation courses, preferential admissions, early admissions, and loan repayments. The Washington (state) Academy of FP has physicians that work with all high schools and colleges on medical careers. Some county chapters have science or math awards for outstanding students.
The decision for rural practice is a whole series of decisions throughout the years of education and training. Rural background is an important factor in placing rural physicians. Students from rural areas need support and guidance. Medical school admissions committees are the next hurdle. The medical school environment holds other obstacles - urban hospital-based subspecialty role models, urban spouses, and an addictive life style. Few residencies prepare residents for rural practice. A choice which demands personal maturity, professional competence, and a great capacity to care for people. The following is a brief summary of some critical areas.
Low Priority for Rural Education see The Continued Centralization of State Educational Resourcesand the Potential Impact on the Location of Young Professionals
Rural health, rural education, and rural economies are completely interdependent. They are also all desperately in need of investment. At least four state's rural school districts have sued the state over maldistribution of educational funds. This lack of funding contributes much to the overall picture. Appalachian females in 1860 were among the most highly educated females in the world. The Civil War and constant strife resulting from economic and political disaster (Appalachians were suspected union sympathizers) led to three generations of no schools. Appalachia suffers the results to this very day.
The Early Years
Medical schools face declining numbers of rural applicants. There are many reasons for this decline. Admission committees seem to lack understanding of the differences in rural and urban students. Rural students may lack GPA and MCAT scores, but they show better interpersonal and community skills. Math and science are noted to be deficient in rural areas. Students who do not turn on to science will not choose health careers. Various programs can increase science interest, the first of the decisions along the pathway to rural practice.
Improving Science Interest - Various programs stimulate interest in science. The AMA has a Natural Science Ambassador program.2 Medical schools such as Tufts and Baylor have ambitious science education programs. Urban science museums sponsor innovative programs as well. Minorities lag some 4 years behind non-minority students. They also lag in medical school admissions. I suspect that rural students lag some 4 years behind as well. They have even less access to science programs and initiatives.
Secondary Education
This is a time of learning relationships. More abstract concepts face students pursuing science interest. Quality teaching and laboratory experience are important. BioPrep is a longstanding program located in the Mississippi Delta. The target for this program is science and math enrichment. The program has stimulated teachers involved in this project to become rural physicians. It enables underprivileged rural children to fulfill their dreams. Computers are utilized in Texas Learning Technology Centers earth science programs. Eighth grade students do experiments with the aid of a computer, saving lab time, equipment, and expenses. Again most of these programs aid urban schools, but the savings in resources would be most important to rural schools.
Role models and counselors are important at this level. Early experiences with health care can influence students in this direction. With fewer and busier providers, the decline of this influence is an expected result. At workshops for rural students, the students note that their counselors are so busy with problem kids that they do not have the time or inclination to help them with career counseling.4 Millicent Gorham, the Washington DC representative to the National Rural Health Association, suggested that the NRHA contact the National Organization of School Counselors to work in this area. She is doing that now. School health professionals are also important. I just wrote the Section on School Health today to ask their cooperation in this effort. Unfortunately schools facing declining enrollments and finance often cut or reduce these positions. School health clinics could help in this area. Rural physicians need to work closely with their schools in these areas. Successful rural recruitment programs such as Kentucky's Professions Education and Placement Program (PEPP) utilize school counselors to identify rural high school students who could become physicians. The local medical society in Bartlesville OK holds a yearly banquet in honor of the areas best science students and teachers. The contact is brief but the message is clear - consider a career in medicine. Other programs discriminate against health careers. Iowa's Youth Job program excludes students from summer health jobs because they are not mature enough. Competing programs for developing lawyers stage competitive mock trials and debates. A very important area involves Community Problem Solving groups. Local and state competitions hone the skills of these groups of high school students. Three years ago the students attacked teen pregnancy. The choice of health topics (as opposed to legal or other) and the sponsorship of rural health professionals would help stimulate these dedicated students. Another potential source to evaluate is teen peer groups. Teen peer groups choose to help one another. This willingness to be involved should not be ignored by admissions committees or those organizing premedical recruitment programs.
ADMISSIONS TO MEDICAL SCHOOL is a critical area. The national average for rural physician production by medical schools is 6% of their output. The current best in this area is East Carolina with 15.9 % rural output. ECU has had four FP's on the admissions committee for years. Wright State has six. The WAMI system (Seattle) uses rural physicians on this committee. Private schools, often receiving just as much state support, have dismal records of producing rural physicians (2 -3 %). Perhaps the best indication of appropriate admissions is the family practice match. Marshall, Mercer, and others exceed 40%. As medical schools prepare for specific rural community-based training, the admission of primary care and rural preference students becomes even more critical.
One option in this area is to target the more rural background candidates for special admissions programs. Nebraska's Rural Health Opportunities Program accepts ten freshman college students each from Chadron and Wayne State Colleges into the medical school. After three years and appropriate courses and grades, they enter medical school. These students come from towns of 300 to 2000 population from the most rural areas of the state. Chadron itself is a town of less than a thousand. By 1994 twenty of the 120 entering medical students will be in this program.
SHAPING THE MEDICAL SCHOOL ENVIRONMENT Those with rural interest must be identified and encouraged. In some medical schools they may need to be isolated from other students or faculty. Rural Student Interest Groups may be helpful in this area. These groups identify students with family practice or rural interest as early as possible. These students meet with each other, with rural faculty, and with rural preceptors in the first two years for information and support for rural experiences, for realistic and practical information on rural practice, for consideration of special rural training experiences, and for career counseling. The rural students themselves are a major resource. They can develop programs to meet their own needs. The Rural Health Career Fair at ETSU is such a program. The Rural Student Interest Group began this annual fair for high school students from underserved areas of the state. After all, if they know they are choosing rural, they will need physicians graduating behind them to be rural colleagues in the future. They have a big stake in the future of medical education for rural practice.
SPECIAL RURAL TRAINING PROGRAMS allow students to fully appreciate rural practice and the role of the rural physician. Nebraska sends all of its 120 third year students into a two month rural family practice clerkship. It also gives them three weeks of rural training at the end of the first year of medical school. The Appalachian Preceptorship instructs 12 students each year in the basics of rural practice, the role of the physician, and the effect of an individual's beliefs and culture on health delivery. Students then spend 4 weeks in a rural community, armed with the curiosity that will allow them to probe the practice, the community, and the physician. The Rural and Community Medicine rotations for our family practice residents do much the same. Rural practice cannot be taught from a book or in a lecture. It is dynamic and must be seen and examined in person.
THE "HANDS-ON" APPROACH Students who plan rural health careers need to experience the responsibility of patient care first hand. They should manage patients in the clinicas and at the hospital. Students should aggressively pursue competence in decision-making as well as competence in procedures. The learning curve is maximized when students get to actually practice medicine with appropriate and available supervision. Students should choose residency programs that will facilitate these rural goals. Students and residents at Veterans or county facilities often have this chance to practice. Faculty should assure supervision and the opportunity to actually do the procedures. Faculty must also make a commitment to "hands on" by learning and teaching procedures in patients or in seminars. Training in suturing, EKG interpretation, casting, and splinting are very popular with students. All Nebraska family practice faculty go out to rural sites to visit with the physician-preceptors as well as the residents. One of the resident's advisory sessions occurs at this time. This visit reinforces the mission and vision of the institution and department.
FELLOWSHIPS IN RURAL MEDICINE Fellowships can emphasize the rural difference. Fellows concentrate in areas that will facilitate their chosen careers. Rural fellows often concentrate on procedures, obstetrics, and rural practice management. They may have an idea of the type of practice that they desire, or they may need to examine several types of rural practices. Other fellows choose experiences leading toward a career as a rural faculty member or rural health administrator. The presence of fellows at the university tells students that rural medicine is rewarding and challenging. Students in this environment learn to respect rural practice and practitioners. Fellows add to the critical mass necessary to establish and maintain quality rural medical education and can support rural satellites and procedural training of residents and students. Fellows can also provide locum tenens in exchange for valuable practice and practice management training.
RURAL FACULTY DEVELOPMENT Rural faculty who attend ETSU's Minifellowship in Rural Medicine train specifically in rural medical education, rural health policy, and rural curriculum so that they can return to their own programs and best advise rural-interested students and residents. These minifellows prepare programs and rural projects that facilitate the advance of rural programs at their home locations. Minifellows work with consultants in rural health and each other to support these administrative and educational goals. Minifellows must also return to their home programs with the skills and motivation to educate program directors, administrators, chairmen, and others. All rural faculty and their staff should have more than a basic understanding of rural medical education.
SUPPORT FOR GRADUATES WHO CHOOSE RURAL The most critical area in the planning of a comprehensive rural health program is support for graduates. Investments at all other levels can be lost if the state does not have excellent recruitment and information programs. Loan repayments can begin prior to graduation to funnel candidates into a rural decision. Care should be taken to inform and screen rural interested residents so that there is a high likelihood of retention as well.
State support includes reimbursement policies for Medicaid and other insurance and support for rural practice modes such as Rural Health Clinics and Community Health Centers. States vary in liability climate. States with high liability costs may discourage the full range of practice that rural physicians can desire. States also vary in the support for rural-friendly legislation and programs. This support can impact on state policies, state programs, or academic departments.
Departments of Family Medicine should work to establish a network of rural family physicians who can assist in teaching and otherwise encourage students and residents to pursue rural careers. They benefit from support from the program as they act as part-time faculty. This also results in increased retention of these rural physicians. Successful rural programs such as the Minnesota's Rural Physician Associate Program become institutionalized when graduates who chose rural locations then become the teachers of new generations of RPAP students.
States want to be sure that their tax dollars are used wisely. The best rural producing programs may end up losing graduates to other states if the state does not attend to some of these important areas.
Rural practice incentives such as loan repayments can be very important. The state of Tennessee has an innovative loan repayment program that repays $50,000 for 30 months of service in rural Tennessee. Another $25,000 is included for practice start-up expenses. Solo physicians receive $5000 locum tenens coverage each year. Technical assistance is available to new physicians. Tennessee has recruited 71 doctors in the last two years and will recruit another 13 this year. Many other states have loan repayments, community match programs and other incentives.
Geographic differentials in Medicaid and insurance programs need to be eliminated or modified to better support rural physicians. Medicaid eligibility and reimbursement policies regarding obstetrics can support or discriminate against rural physicians. The state also determines the complexity of the program.
Faculty who visit rural physicians and communities can be a great help in social support, occasional coverage, specific training in procedures, and as a consultant to rural practices. They can help identify community health problems and refer communities or physicians to sources of assistance. Faculty can facilitate the grouping up of solo physicians to aid in teaching, recruitment, and retention. Common methods of assisting rural communities or hospitals in distress are community needs assessments, strategic planning, and training for hospital boards.
KEEPING HOME-GROWN PHYSICIANS AT HOME Many students have attended state colleges and state medical schools and are looking for or are told that they need a different experience. Since residency program location influences the location of practice, many state tax dollars are lost to other state. Oklahoma pays students who choose FP programs in their state a $5000 bonus and an extra $1000 a month. When they choose a community, they can receive further funding. This program keeps good quality candidates at home.
Rural physicians often receive guarantees of $110,000 a year or more with other practice assistance and free rent. Some have received signing bonuses of up to $40,000. Procedurally trained physicians may receive even higher offers. Antitrust "Safe Harbor" rulings by the courts may interfere with the rapid acceleration of rural physician salaries and benefits, but the incentives for finding and keeping a rural physician are limitless in variation and amount. Many hospitals may want to combine of private practice and 8 - 12 hours a week in the ER to support and attract new physicians as well as improve the community's attitude toward the hospital.
FINANCING RURAL PROGRAMS Rural areas that are Medically Underserved (MUA) can have Rural Health Clinics, Community Health Centers, or Federally Qualified Health Centers. Rural Health Clinics and FQHCs involve capitated reimbursement that often exceeds RBRVS rates. CHCs receive grants for operations and indigent care, have a sliding scale, and a community board. Special grants to CHCs or rural hospitals can finance graduate medical education, in addition to the traditional Medicare GME sources.
Rural medical education can be more or less costly than the traditional urban-based programs. Spokane's Rural Training Track costs $60,000 per resident per year compared with their usual resident cost of $120,000. RPAP students may generate $20,000 - $70,000 in increased billings for their preceptor's practice. This partially offsets the $9000 each preceptor pays to support each student. Most rural preceptors across the nation volunteer their time for teaching and in some cases housing and living costs as well. Rural communities are realizing the value of long term recruiting as these few thousand dollars compare to the $35,000 or more expended in recruiting a single physician. Those developing rural programs should be wary as there is a danger when "using" the desperation of rural commuities (for physicians) to finance rural programs. The expectations of the programs, the communities, and the state must be realistic.
Setting up new programs and hiring extra faculty and staff can make startup of new programs costly. Travel and housing costs for students and faculty, faculty development, site development, and other specialized training costs can eat into ever tightening budgets. Rural practice revenues are not as lucrative as the usual medical school practice base; however, rural programs can be very valuable in funneling patients into regional medical centers and financing can be negotiated from this strength. One way of looking at rural programs is to examine the financial impact on a site. The addition of one or two residents or a faculty line can add $300,000 and more than ten jobs to the local economy.
The investment cost is high in terms of time, dollars, and the stress of effecting change, but the need for rural physicians is higher.
HAVE STUDENTS INTERACT WITH PRECEPTORS, NOT OTHER STUDENTS - If two or more students gather together, they are more likely to bond with each other and focus on the clinical milieu or their misfortunes, while ignoring the work of the preceptor and his or her relationship with patients and community.
IMPROVING THE TEACHING IN RURAL PROGRAMS - in development
EFFECTIVENESS OF RURAL PROGRAMS - in development
A FINAL SUMMARY
Rural medical education differs from current medical education in many positive ways. Rural medical education restores the emphasis on the delivery of basic primary medical care. It can also provide more student-oriented training as opposed to the traditional faculty orientation of the medical school curricula. Rural training occurs away from the ivory tower environment of disease-oriented subspecialists. Medical students and residents can also learn more in rural community-based programs by actually doing, rather that watching. They accept more responsibility and this acceptance leads to greater educational value.
Attention to rural programs will provide some security for medical educators to avoid further state regulation regarding curriculum or program development - thus avoiding the difficulties of mandated systems. Mandation can often inhibit one of the strengths of academia - innovation. Since the current system is failing, innovation is greatly needed.
A coordinated comprehensive program is the best method to stimulate and maintain rural interest. It prepares students and residents for longer, more productive careers. It also provides a measure of guarantee to state agencies that the needs of the state will be met and that tax dollars are used effectively. Without such a program, the increasing competition for the few primary care candidates will crowd unorganized states out.
A coordinated program includes pre-professional, professional, and post professional factors. Communities must assess their health needs and support their local providers. Recruitment is important but retention is even more important. States who work with communities and medical education in these areas are in the best position for improved rural health care.
Rural medical education is good for medical schools, good for the students, good for the state, and good for the country.
Nebraska's Rural Programs
Information
"The Rural Family Doctor" - an informative newsletter for current and future rural physicians
Rural Database of rural faculty, rural and family practice program directors and others nationwide in organizations and government who are interested in rural health
State Legislative efforts for the production of rural physicians
Continuous Rural Programs
Rural Research Efforts
Interview Study of Rural Physicians - a study of why physicians stay, adapt, and thrive in rural areas.
Rural Background and other factors in the Decision for Rural Practice
Practice Decisions of Family Practice Residents - an ongoing prospective interview study of all family practice residents to help in the design of curriculum to aid recruitment, retention, satisfaction.
Family Practice Graduates and Rural Communities - community characteristics associated with recruitment and retention of family practice residency graduates. Useful for communities and faculty.
Defining Rural Faculty - a Nationwide Survey
Defining a Rural Curriculum - for the preparation of physicians for rural practice
Programs for the Production of Rural Physicians
Rural High School Health Career Fairs
Rural Medical Student Interest Groups
A Review of Rural Preceptorships
Rural Core Rotations
Rural Training Tracks
Facilitating Recruitment of Residents to Rural Practices
Financing Rural Programs
Faculty Development for Rural Family Practice Faculty
Minifellowship in Rural Family Medicine
Preceptor Education materials
Rural Initiatives/Rural Health Policy regarding training grants utilizing a survey of rural faculty
Retention of Rural Physicians - the community factors
ETSU's Rural Programs
ETSU as a Source of Advisement for rural faculty, students, residents, physicians in practice, and institutions
Information
"The Rural Family Doctor" - an informative newsletter for current and future rural physicians
Rural Database of rural faculty, program directors and others in organizations and government who are interested in rural health
Rural Research Efforts
Assisted with the Johnson County Health Survey - "What do rural people want in health care?" This study examined 10% of the population of 14000 in a small rural county in northeast Tennessee using house to house interviews of all family members.
The Appalachian Preceptorship - A Status Report of the past seven years for this medical student program. It includes information on development of this program and suggestions for future programs. It includes the results of the program including its effectiveness in producing rural and primary care physicians
Interview Study of Rural Physicians - enough of studying why physicians leave practice, this is a study of why physicians stay, adapt, and thrive in rural areas.
Practice Decisions of Family Practice Residents - an ongoing prospective interview study of all family practice residents to help in the design of curriculum to aid recruitment, retention, satisfaction.
Family Practice Graduates and Rural Communities - community characteristics associated with recruitment and retention of family practice residency graduates. Useful for communities and faculty.
Defining a Rural Faculty Member - a Nationwide Survey "Is there such a person and how are rural faculty different?
Rural Initiatives/Rural Health Policy regarding training grants utilizing a survey of rural faculty
Defining a Rural Curriculum - utilizing a survey of rural faculty
Production of Rural Physicians - Medical School Factors
The Pipeline to Rural Practice