Dispersed or Decentralized Training

Fowkes VK, Gamel NN, Wilson SR, Garcia RD. Effectiveness of educational strategies preparing physician assistants, nurse practitioners, and certified nurse-midwives for underserved areas. Public Health Reports 1994;109:673-82.

Community Driven Approach

Helping Residents Adapt To Rural Training

I was particularly heartened regarding the McMaster experience with dispersed residency training. About 60 of our US FP residencies have some of this dispersed component and a handful of medical schools. The only evaluative work has been in the Rural Physician Associate Program in Minnesota (9 months in 3rd year) where students equaled or bettered their colleagues who stayed in Minneapolis. 

As Don McLean (McMaster) noted as they implemented rural rotations (numbers added, the rest a quote):

  1. "A number of problems were anticipated, but most did not materialize;
  2. The residents do not seem to be bothered by the necessary travel or isolation - but they all choose this "unit" as 1st choice.
  3. Their community supervisors are (mostly) considered excellent teachers by the residents . They're carefully selected !
  4. Ongoing monitoring of the residents' experience and the community practices is essential.
  5. The academic component of the program must be maintained , so it doesn't become or appear to become an apprentice program . The residents all return to the university for a half day for behavioral science, and another academic half day , as well as organized rounds at their local hospitals.
  6. The program does require considerable administrative support , and needs commitment from the full time academics to maintain the academic input."

Thanks Don, I have seen no better guide to dispersed training than the above. In the US people have been married to a medical education model that gives very little primary care priority or experience. It baffles the learners with a barrage of information and allows learners little access to those who can deal best with uncertainty and handle such a wealth of information. Even more puzzling is years of clinical training where students (or residents) have supervision for rarely more than 3-4 weeks at a time. By the time they are learning about the supervisor (and vice versa), the end of the month comes and attendings, residents, or students move to the next round. Learners suffer as no one really gets to know their strengths and weaknesses.

The lack of continuity in education is a primary impediment to medical education in this country. Not every faculty member can be a Jack Verby in Minnesota who gave 20 years of his life to RPAP. Not every state gives $1 million a year for a preceptorship model medical education program as Minnesota did, but few medical schools have tried, and fewer still have asked for the money to fund faculty who could initiate and supervise the program.

Other items of interest:

  1. RPAP students start out 25% lower than the other students on initial measures.
  2. 60% go to towns of less than 50,000
  3. RPAP students are a greatly valued by program directors and their resident colleagues.
  4. RPAP students are overwhelmed by primary care at 3 months, neutral at 6, and don't want to leave at 9 months
  5. RPAP students actually supply workforce, they are not a burden. Practices bill for thousands more when they have RPAP students.
  6. The RPAP program had to deal with both students and preceptors who were not capable (drugs, alcohol, mental health, etc.) of doing their duties. This is a measure of the interaction.
  7. RPAP students have gone on to become leaders in family medicine in research and service, including the current STFM President.
  8. RPAP depends upon the admissions and educational experiences of the Duluth program where many RPAP students start their medical education (courteousy of Jim Boulger and others). I don't think the value of RPAP is in its rurality, it is in the continuity and involvement of the learning experience. As we face a time in medical education when students seem to observe more and do less, there is another way of learning that is far beyond the model stage.

Why do we put so little value on the word preceptor. The problems of a century ago had to do more with proprietorships, not preceptorships. Yet we seem to regard preceptorships as ancient, outdated, and unworthy. Will we choose to remain captives of the side effects of the Flexnerian Revolution, or will we focus on what is best in medical education?