Robert C. Bowman, M.D.

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Short and Sweet on Accelerated Family Medicine Training Programs

Accelerated Family Medicine Training Programs

The University of Nebraska Medical Center (UNMC) received approval from the American Board of Family Practice (ABFP) in 1993 for an accelerated family practice training program. The Nebraska program extended the usual 3-3 format to a 3-3-1 by adding a one year "rural procedures" fellowship. Accelerated residents were also required to commit to practice in rural Nebraska. The Nebraska Accelerated Rural Training Program (ARTP) has recruited 9 classes with 4 in each class and 24 have selected their locations. Half of the graduates have chosen towns of less than 5000, 3 have chosen towns of 8000, and 3 have chosen towns of 25,000. UNMC is now adapting the model into an inner city underserved track. UNMC has created a new model that provides additional opportunities for graduate medical education to meet the unique needs of underserved areas.

The nation depends on medical education to prepare the physicians needed for an increasingly diverse country with the widest range of health demands in the world. Top medical education experts, past and present, continue to recognize the need for the best physicians to go to small towns to practice. Osler Flexner However, the numbers of senior medical students interested in rural practice in towns of less than 10,000 has declined to 338 out of over 13000 respondents. AAMC GQ Schuchert Bowman

Family Medicine has, in great measure, assumed the responsibility for providing care for underserved populations. Policy Center Report. These are major accomplishments, but Family Medicine has fallen short of some lofty expectations. Despite major increases in the numbers of family medicine residents, there has been no significant increase in the numbers choosing rural locations over the past 30 years. Bowman

More recent research may help explain why. Studies by Rabinowitz have noted that 78% of the decision for rural practice involves the medical school applicant characteristics of rural background and family practice interest (Rabinowitz, JAMA sept 5th).

Rural physicians, therefore arise mostly from decisions by admissions committees and deans. Efforts to reform curricula or attract more medical students into Family Medicine would not be expected to change the numbers choosing underserved locations and this has been confirmed over the past 30 years of graduates. Without changes in admissions, Family Medicine will continue to graduate only about 700 into rural practice each year AAFP DATA , barely enough to meet current levels of attrition and certainly not enough to address the additional needs of shortage areas.

Should the following be in a different article, the Underserved, rural, inner city, and medical education

Inner city areas are more dependent on minority physicians. AAMC studies show that underrepresented minorities are 4 times more likely to choose underserved locations. These are not likely to be rural locations as family practice programs with more minority residents were the least likely to graduate rural physicians (Bowman and Penrod). Data from the AAFP in the 1990s was initially encouraging for inner city poverty locations with increases of family practice graduates up to 6%, but this percentage has declined in recent years.

Recognition of these important areas has been slow in coming. Only this year has Jordan Cohen, M.D., the President of the Association of American Medical Colleges (AAMC), emphasized the importance of admissions in selecting candidates that would be more likely to choose underserved areas. Cohen AAMC Annual Nov 2001.

In the mean time, retention of existing candidates remains a key concern. It will be years before these changes can take effect. This is due to the length of medical training and the difficulty of changing medical school admissions policies. Pathman has suggested that the type of training provided by medical schools and residencies might be a significant way to impact retention. Pathman RME. Family Medicine has developed specific guidelines for both rural and inner city graduate programs. Family practice program directors generally do not recognize the need for specific training. In one study 89% thought their graduates were well prepared for rural practice Murray . A recent survey of directors used to prepare for their annual meeting noted that few desired presentations in rural graduate topics (PD Survey).

New rural training models have attempted to prepare graduates for rural practice. The Rural Physician Associate Program in Minnesota originated when a Minnesota state senator led efforts to force improved training on the medical school. John Verby developed this program and demonstrated that graduates of RPAP had the same quality of education and had additional procedural, behavioral, and clinical skills after 9 – 12 months in a longitudinal rural preceptorship Verby . The RPAP model also illustrated the importance of connecting rural-oriented admissions to rural clinical experiences as half of the RPAP students come from the Duluth program where rural background students have preference. Boulger

Medical schools have been slow to accept this model. Resistance forced Verby to learn educational assessment and research techniques to maintain and prove the worth of the program. RPAP graduates have distributed throughout Minnesota and the upper midwest and have contributed over a billion dollars of economic impact to Greater Minnesota alone since 1971. Without a courageous Chair of Surgery at Syracuse, the program would not have been replicated at all. He took the time to call the Minnesota Department of Surgery and verify the success of the model. This Chair stood up and supported the RPAP model at Syracuse and the faculty agreed to support it. The Syracuse model continues to do well. Had Verby not . made the extra efforts to work with surgery and other Minnesota medical school departments to explain the model and take key faculty on rural visits, the program would not have been replicated at all. Verby and Baird..

Initiation, development, and recognition of rural graduate programs has also been a problem. Many medical educators have continued to doubt the quality of preceptorships even after studies have validated their worth (Gjerde, Verby). After the initial Spokane model, the Residency Review Committee resisted replication of the Rural Training Track model (Maudlin) and forced it to be so much more complex that it was more expensive and less likely to meet the needs of the smallest rural areas. The American Board of Family Practice holds the key that would open the door to new accelerated programs. Responding to pressure by family practice residencies that could not set up such programs, the ABFP placed a moratorium on new programs.

The history of medicine reveals resistance to multiple innovations such as aseptic technique, anesthesia, and the Germ Theory. Pioneers such as Semmelweis and Paponicolau endured decades of criticism and ostracism. Those involved in medical education for the underserved should be prepared to endure.

Delays in replication and the smaller numbers involved in RTT programs have delayed research to demonstrate additional advantages for RTTs. Other experts have outlined the educational needs of rural physicians, the potential of rural fellowships, and recommended improvements in the methods of training for rural practice Bergus, Acosta, Norris

States such as Nebraska can ill afford the luxury of waiting on final outcome studies to point the way to a definitive intervention. States in the midwest and south have significant shortage needs. Counties with less dense populations in the midwest and west with less than 10,000 people have difficulty attracting the critical mass of 4 physicians noted to be important in previous studies Madison and Cooper and gather enough patients to maintain a hospital and a viable rural health system. Nebraska ranks second in the nation with 47 of these challenging counties. Nebraska faculty have colleague and family connections with many of these communities and their physicians. This has stimulated the College of Medicine at UNMC to develop numerous initiatives. UNMC faculty have adapted existing models and created unique ones.

The Combined Outstate Residency Experience (CORE) Program is a two month rural preceptorship established in 1982 from the efforts of the DFM and its affiliate program in Lincoln, NE. Faculty send a continuous stream of residents to each of 4 rural sites. Each town remains CORE site for up to a 3 year period. Usually the site is in need of 1 or 2 physicians. Residents share call, support local physicians, and contribute to the viability of the rural health system while learning about rural practice. Communities also improve their recruitment by learning first hand from their prime targets, family medicine residents.

The Four Year Combined Primary Care Program began as an effort in the late 1980's to graduate residents with board certification in both internal medicine and family medicine. The efforts to develop a 3-1-3 program paved the way for the accelerated program.3 O’dell Sitorius

The UNMC Rural Training Track (RTT) program, initiated in 1992, has grown to a separately accredited residency with 5 RTT sites spread across the state (Grand Island, Kearney, North Platte, Scottsbluff, and the new Norfolk site). After an initial year in Omaha, each resident branches out to a site with two resident slots per site in each year of training.

The opportunity for the accelerated program presented in 1991 when the American Board of Family Practice (ABFP) issued a request for proposals to replicate the success of the original University of Kentucky accelerated program. UNMC answered with a proposal that would adapt the original 3-3 model into a 3-3-1 program. The ABFP stipulated that no more than one-third of an entering residency class could join an accelerated class, therefore 4 students began the new program in July of 1993.

The Inner City track, initiated in 2000, began as a few residents and faculty moved their clinical operations to the Indian-Chicano Community Health Center. This program was a recognition of an increasingly diverse population in the state with unmet needs.

The Inner City Accelerated Training Program is now pending approval at UNMC. This involves a more comprehensive curricula with the inner city clinic, rotations in other urban poverty locations and community health centers, and increased emphasis on public health and population-based medicine.

The rural needs of the state presented the initial challenge for UNMC educators. They theorized that, as the smaller rural hospitals closed, the surviving small rural hospitals would need a cadre of 3 – 5 well-trained family physicians. Graduates with additional procedural capability would improve the viability of rural practice and capture additional market share for rural health systems. These accelerated graduates would need to be comfortable working with physician extenders and with each other to support a reasonable call schedule and the balanced workload preferred by new graduates (and old).

The ARTP program is described by Stageman, Bowman and Harrison. Key points of the model include the commitment to rural practice, the financial incentives (loan forgiveness), the specific tailoring of the M-4/PGY-1 year to allow trainees to function and meet increasing responsibilities, and the flexibility of the fellowship year. Nearly all components of the program are adaptable into inner city-oriented training.

The program has recruited 9 classes for 34 total residents. Of these, 25 have come from small towns with the rest originating in Omaha or Lincoln. All 24 graduates have become board certified, 18 of 24 (75%) have continued into the 4^th year or training, 20 of 24 (83%) are practicing in Nebraska, 12 (50%) located in towns of less than 5000, 3 chose towns of 8000, 3 chose towns of 25,000, 6 have chosen urban locations, and 7 located in whole county federal shortage areas.

Accelerated residents have had no difficulty in adjusting to residency training. They have been well-accepted by the other members of the residency class. They have demonstrated the same levels of academic growth based on standardized testing. In addition, accelerated residents have developed their own esprit de corps. They have taken an active role in the development of the program. They see future graduates of the program as potential colleagues or replacements and this has been confirmed upon graduation with pairs of graduates at 3 locations. The impact of colleagues on practice location is another area recognized as likely to be important but not yet researched.

The following table compares the ARTP program with the RTT graduates. The table describes similar outcomes regarding graduation into towns of less than 5000. The RTT program began first and graduates in the first few years of the RTT chose these towns in high percentage. This was also true when Family Medicine first began graduating residents over 30 years ago. Both models share the tendency for residents to go into practice together. The accelerated program has filled all available slots every year. The RTT programs have had more difficulty filling slots, particularly during the first few years for a new site. Addition of the ARTP has not seemed to make recruitment more difficult. Attrition has been higher for the RTT with about 1 our of 8 residents choosing not to continue on to the rural site for the final two years of training.

Thanks to Jeffrey Harrison, M.D., for RTT figures.

The Accelerated Rural Training Program model can graduate residents who choose to practice in the smallest towns, even when the model includes 7 years of medical education almost completely in an urban location.

There are some educational advantages of the program. The ARTP puts two superb learning years back to back. Accelerated residents experience a steadily increasing gradation of responsibility. The unique characteristics of the program may fit certain types of residents better. These include those with spouse or family needs to remain in Omaha. Also those who are less self-directed may benefit from the structure of the accelerated program as opposed to a rural training track where the best education may need more individual efforts from residents. Accelerated residents can also moonlight a year sooner than their peers.

One of the real advantages of an accelerated program may be acceleration of a decision for rural practice or at least a final confirmation of an initial pathway. In a typical residency program, residents may not seriously consider a final location until a year or two before graduation. AAMC GQ data reveals that 30% of senior medical students interested in rural practice decided on this pathway before medical school. Only 15% of all senior medical students knew their career plans prior to medical school. AAMC GQ An early decision for rural practice may include more than a financial commitment. Accelerated residents seem to have set a career pathway and attitude that structures electives, rotations, moonlighting, clinical experiences, colleague contacts, and decisions regarding family and personal issues. These issues may be important for physicians who prioritize service and plan to care for underserved populations whether rural or urban in location.

The fellowship year offers some distinct advantages for those interested in education that meets the needs of underserved areas. Accelerated fellows can tailor their training to their needs. Many know where they plan to practice. They can train specifically for these locations. Some fellows have been able to take rotations from the consultants that they will work with for many years following graduation. Given these additional considerations, it is possible that an accelerated model may improve retention in a rural location. Other than a few rural rotations, the rural training track model, and the as yet unreplicated accelerated rural training model, little has been done to explore this area. Given that the loss of a primary care physician results in nearly a quarter of a million dollars in losses and replacement costs, retention must be a high priority for family medicine graduates for underserved areas 12 AHCPR.

Specific accelerated tracks for urban and rural underserved areas might allow graduates to prepare more fully for some of the advanced problem-solving needed as primary care interfaces with community medicine, increasingly diverse populations, quality of care concerns, practice management issues, mental health, education, public health, and government. Again AAMC surveys of senior students reveals that students see this as areas missing from the medical school experience. AAMC GQ 2000 It may be that until physicians gain a reasonable mastery of medicine, they will not extend their problem solving skills beyond this limited arena. Will physicians continue down a pathway that will delay their medical development and limit their potential as societal leaders? Mastery of medicine involves increased patient care responsibilities and a certain volume of patients. Recent decades have seen decreases in the numbers of patients accessed by trainees through the loss of indigent facilities and numbers. Trainees have had fewer opportunities to make patient care decisions. Recent studies have begun to examine changes in the competency of physicians over time, but the focus on resident training may miss the more global impact of changes in medical schools Competency articles in JAMA Accelerated tracks may be one way to restore confidence, add competence, and enhance leadership potential.

Some of the unique characteristics of the Nebraska medical education environment may have contributed to the success of such a rural medical education model. These include the tendency of UNMC medical students to come from small towns, to stay in state residency programs, and to return to state locations. Also UNMC had already acted to improve admissions of those from small towns and others likely to choose rural practice. This involved particularly a past medical school dean, an associate dean of admissions who was a former rural physician, a chairman of Family Medicine who was the son of a rural physician, and an associated dean of graduate medical education that had done significant rural workforce research. Nebraska has required all medical students to do a two month rural family practice preceptorship for over 50 years. First year students also spend 3 weeks in rural Nebraska, this is their first continuous clinical experience. Another key asset was an experienced program coordinator.

The connections and timing of program development are key considerations for those considering the development of rural graduate programs. Rural training tracks have had difficulty attracting students. Perhaps part of this problem is not having likely candidates available to fill residency slots. It would have been difficult to fill all of the various rural tracks at UNMC had this all not been in place. Inner city graduate programs would need candidates interested in serving diverse populations. Underrepresented minorities and those who have previously worked in underserved urban areas in the United States or overseas would be strong candidates.

Urban areas and also many of the rural counties in need have large geriatric populations. Fortunately geriatrics is a strong point of the UNMC Family Medicine residency program. Others may need to fortify this area for accelerated graduates to do well.

Other locations may have an easier time adapting to certain aspects of the model. Medical schools with procedurally active family medicine faculty might have an easier time setting up the fellowship year. Rodney demonstrated the educational and financial success of a rural obstetrical outreach model in Tennessee. Many medical schools and residency programs have limited opportunities to learn obstetrics first hand. Some academic locations (Greenville NC, College Station TX, Johnson City TN, Columbia MO, others) may have a nearby rural clinic where accelerated residents could see rural patients throughout their 4 years of graduate training. In Nebraska, two nearby towns offered this potential but one was a bit distant and the other site rejected approaches. Urban areas offer tremendous potential for partnerships between community health centers and academic programs. Some medical schools such as Baylor have worked closely with neighborhood centers for decades.

If the accelerated model is successful in meeting its original goals, there is great potential for graduates of the program to improve health care in a number of areas.. The broader skill set would improve access to a wider variety of health services. This would likely improve local market share and increase practice income. Market share is a key component of rural health system viability. Urban clinics would also benefit from increased services and procedures. Increases in market share for rural hospitals have been shown to be more important than increases in Medicare and Medicaid reimbursement. Hospital Project? Health is also a big portion of the rural economy, often second only to local schools. Rural physicians and hospitals can involve up to 25% of the economic impact in small towns Doeksen

If specific rural training results in improved retention, there are other impacts to consider. Rural physicians contribute to the local pool of leadership and help attract and support other young professionals. Long term physicians can anchor rural primary care and hospital services. Community centers in urban areas can provide leadership and help improve education and other important components of life.

The efforts of UNMC leaders and the successful focus of the graduate programs on the needs of rural Nebraskans resulted in the Department of Family Medicine winning the Program of the Year Award from the National Rural Health Association in 2001. In one sense, Nebraska’s award is bittersweet. This is certainly a nice honor and UNMC is not the only medical education program to win (Duluth Family Medicine was a previous winner). The tragedy is that the award was, in part, a recognition of the fact that few other medical schools have embraced an approach that focuses admissions, training, and outreach on the needs of rural communities

Medical education in the past century has failed consistently to meet the needs of society. Rural medical education continues to be ignored because medical leaders quickly dismiss the complex problems of underserved communities as a function of the poor rural economy Cohen, Newhouse It is hard not to ignore the purely economic arguments, but physicians are not just dependent on collections of adequate resources and population, they also contribute to the economy.

Bracho and others have critized medical schools who fail to address the needs of underserved right in their own backyard. Bracho, stfm presentation This means a very different approach for medical schools. They must look beyond a focus on what others can do for them and learn to understand what they need to do to understand to help address the needs of underserved communities. Now that the relationship between admissions and recruitment to rural practice is more clear, medical schools can no longer ignore such issues.

If medical schools do not admit students that are likely to choose underserved areas, they are depriving these communities the basic assets needed to improve economics and other areas. Physicians bring economic impact, jobs, leadership, and better access to health. Such communities cannot attract new jobs and retain current ones without ready access to health care services. Failure of medical schools to do all that they can to graduate and retain rural physicians is likely a major factor in failing rural economies. This may be more pronounced in the smaller rural communities.

Family Medicine itself has been examining its goals, progress, role in society, and other issues. The recent Keystone conference explored several of these issues. List serves for chairs, program directors, faculty, and rural medical educators continue the discussion. Since the re-creation of personal physicians for families, Family Medicine programs and departments have obtained funding based at least partially on the potential to meet the needs of underserved populations. A key theme involved is:

Will Family Medicine take a more active role and stand in the gap between medical schools and underserved populations or will it prioritize other areas?

In more recent years, Family Medicine has taken a less aggressive approach in this area. The examples noted above regarding the RRC are one example. Currently there is a moratorium on the development of new accelerated programs. Given the needs of underserved populations, the needs of Family Medicine to justify ongoing support, and the needs of medical schools to become more societally relevant, Family Medicine needs to become more active in this key area.

Lifting the moratorium on new accelerated programs would be a good start. Some residency programs have expressed concern regarding the advantages such programs have regarding the match. In traditional accelerated programs, this advantage is highlighted by 6 years of education compared to the usual 7. Nebraska’s program maintains the 7 years as well as a requirement for graduates to serve in rural areas. Perhaps such requirements would level the playing field. Also academic programs could work more closely with community-based programs, community health centers, and other facilities to set up accelerated rural and urban underserved programs.

Widespread adoption of the accelerated model could certainly focus attention on the needs of underserved populations, but there is a danger that the model would be used by others with different agendas. This could be Family Medicine or it might involve other disciplines. For example it would be just as easy to have an accelerated track that graduated faculty, researchers, or MBA physicians. Care of the underserved needs to remain a top priority of Family Medicine until significant progress is made. Family Medicine should continue to prioritize programs that offer the potential of meeting local, state, and national needs.

Nomenclature note: A 4-3 program has the usual 4 years of medical school and 3 years of graduate medical education (GME). A 3-3 is the usual accelerated program with 3 years of medical school and 3 years of GME. A 3-1-3 involves three years of medical school , one year subinternship, and 3 years of graduate medical education. A 3-3-1 like this accelerated program has 3 years medical school, 3 years GME, and a 1 year fellowship.

Accelerated Models in US

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