Some programs in the US and in Australia are looking at ways to make the curricula more relevant for underserved practices and shortage areas in the nations.
A few years ago the American Board of Family Practice started an experiment to accept medical students into graduate training after 3 years, making medical education a 3 - 3 endeavor. 12 programs began (compared to 400 plus programs nationwide).
One accelerated program out of these 12, took a different route so that it could focus on the rural needs of its state. The Nebraska Accelerated Training Program has 3 years medical school, 3 years residency, and a 1 year fellowship emphasizing procedures. This program in Nebraska is different from the 3-3 programs in 11 other academic locations. It focuses on rural preparation. Meeting the Needs of Underserved Rural and Inner City Areas with Accelerated Graduate Training Australian educators are looking at a similar model.
Others are looking at models that combine a 3rd or 4th year of medical education spent in rural preceptorships (like the Minnesota RPAP or Syracuse RMED), with a 3 year graduate model. This graduate setting could even be a specialized 1-2 rural training track (1 year at main residency site and 2 years at rural location).
Political forces in FP in the past have lobbied against any hint of a need for a fourth year of graduate training, presumably because it makes FP look bad compared to other specialties and because it would be difficult to get students to choose longer training for little if any financial reward. Other politics have worked against accelerated programs. A focus on the match and declining student interest has tended to pit academic and community based programs against one another.
Explanation - Accelerated programs take students a year before they would match. They also tend to be the more desireable students. Community-based programs have not had the opportunity to do accelerated programs. In a pinch for students, they have successfully lobbied to limit this model so that they have a better chance to get the more desireable students.
ABFP says studies on the 3-3 programs are promised, but have not come out. Nor do they have an author's name to mention on this study. Studies on the Accelerated Rural Training Program show excellent location and training, comparable to Rural Training Tracks with 75% in rural locations or more. This ARTP program would also be an excellent model for those desireing inner city underserved training, focusing on inner city clinics, culture, language, community health etc.
Unfortunately the American Board of Family Practice, caught in the middle, has placed a moratorium on all new accelerated programs, even ones that would focus on specific training for underserved areas. The developers of the ARTP program feel that the ARTP model with its lengthy 7 years, the same as standard US medical school and residency training, negates the one year less training advantage of the other accelerated programs. Also the ARTP requires a commitment to rural practice backed up with some financial incentives.
There is also no reason why an academic program could not work with a community-based program or RTT to develop an even better model, since this would have a rural clinical effort that Nebraska's does not have (small town nearby chose not to participate in early goings).
The problem is that medical education is becoming less practical and hands on with every passing year. Students and residents do not tend to get the same opportunities to make decisions and manage patients and do procedures. Different models may be necessary so that graduates feel comfortable going to some challenging locations, such as rural or urban underserved practices. The Accelerated Model puts two excellent learning years back to back, the M-3 and PGY-1 years. The PGY-1 year is tailored to increasing difficulty over the year. ARTP residents moonlight a year earlier. The fellowship year often is used to prepare for a location that is already known.
Programs hoping to attract and graduate residents for underserved areas depend more on selections of the right kinds of students into medical school more than any other area.
For rural underserved, medical schools must choose students with rural background and true FP interest.
For urban underserved the candidates should have minority or lower socioeconomic backgrounds. For both types of underserved, orientation toward service is key.
Trying to develop graduate programs targeting underserved areas without such students is a wasted effort.
The real solution for getting more students into underserved areas and into Family Medicine, is to select the right students - those with service orientation.
This is helpful to balance all the needed ingredients to work well in rural practice settings:
"Physicians occupy an unusual spot in the social structure of rural communities. From an economic standpoint, they are successful entrepreneurs, well-paid business people similar to bankers and lawyers. On the other hand, they are also social servants like policemen or teachers, just as essential to the welfare and functioning of the community but paid for through a fee-for-service mechanism outside of local community control. This anomalous status requires some fairly innovative interpersonal and structural relationships to strike a workable balance." Rosenblatt and Moscovice, 1982 see Establishing Yourself in a Rural Community
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/
Priorities
1. admissions - rural background, service-oriented, lower socioeconomic, older
2. federalize liability for underserved physicians
3. Safety net marriage PC training with GME and underserved
4. Title VII funding targeting early impact - admissions, early experiences in underserved/service
5. Rural GME - paid up front and enhanced
6. NHSC to work closely with small colleges and minorities and admissions to pick the people they want for medical school for the places they anticipate will need physicians
7. Pressure at the state level to get preadmission feeders, improve education and career advising at small colleges and high schools, improve admissions, train in rural areas, use students and residents to support existing rural docs and health systems in exchange for top quality teaching and hands on training, etc. (community-driven approach)
Four Year Residency Example
Certainly there are reasons to be concerned about a four year residency -
match, funding, competition, etc. But there is much to be enthused about.
Eight years ago Nebraska put the final touches on its own 4 year residency
program. Family practice leaders of the times found out about what we were
trying to do and expressed some or all of these negative viewpoints. One
even threatened accreditation problems for all of our residency programs in
family medicine and he was in a position to make things most difficult. Our
chair and program director held fast. The result was an incredible program
? the accelerated rural training program. This program meets the needs of
our state very well. Over 70% of graduates not only choose rural, but
choose towns of less than 5000 population. During this time our rural
training tracks held firm at 75% rural graduates as well.
If we had caved in to the powers that be, we would have had almost as many
rural doctors graduating, but they would have not been as well trained. You
see, the final year emphasizes procedures, obstetrics, neonatology, surgery
skills, critical care, anesthesia, etc. The 4th year resident is actually
able to assist in creating a final year of training to facilitate his or
her needs. Those who know where they are going can tailor their training to
the needs of their community. Also the 4th year can do things, even in the
medical center, because of their experience and the fact that being a
fellow rates in academic centers.
Yes, this is not a true 4 year program because it is a 3 ? 3 ? 1, 3 years
medical school, 3 years of residency, and a year of fellowship. Yes, we
have had folks leave at the end of the 3rd year of residency. Yes, the
program has great selection bias for rural and service orientation, but the
fact that trainees, after spending 7 years in urban Omaha, go out to the
smallest rural towns, is incredible.
There are two major reasons for the success of the program. One is the fact
that the fourth year of medical school is not wasted. Two incredible
learning years are back to back in the M-3 and M-4/PGY-1 year. Residents
are fed material as fast as they can handle it. The second key is also in
the challenges faced by the residents. Dr. Stageman does an excellent job
in making arrangements for the fellowship year. Every year is a challenge
to get faculty or clinicians to work with our fellows in a way that allows
them to learn skills at a high level and do procedures in a number of
areas, often in an area that would potentially compete with the teacher.
The program depends on his efforts to get high quality education that meets
the needs of the residents.
The success of the program highlights the fact is that the current medical
education situation of 4 years of medical school and 3 years of residency
is not a good one for family medicine. Frankly, all of primary care needs
to have a completely different preparation than most medical schools are
willing to provide. A coordinated undergraduate and graduate program is an
excellent way to prepare family physicians for practice.
I would vote for 6 or 7 years of combined primary care medical
school/residency rather than the current situation any day. Problems with
the match, the lack of committed residency candidates, and other problems
would disappear. We need to think more about the needs of communities and
the needs of our graduates, and less about the obstacles, other than to get
around them.
The four year residency, especially 3 years medical school and 4 years of
residency has much to offer, especially for those interested in rural or
family practice only type careers. Some have expressed concerns regarding
the need to have a time to make a decision for a particular career. Also
there was a need to develop a common language. I submit that primary care
physicians have different characteristics, and the common language of
American Medicine needs to be the language of primary care.
Who are Primary Care Candidates?
Studies using AAMC GQ data in 1995 demonstrated that 30% of rural
interested senior medical students knew before medical school that they
wanted to do rural family practice. For them and others who are solidly in
the primary care camp, it is a waste to plod along with little direction,
hence the value of the accelerated rural program, the Rural Physician
Associate program in Minnesota, and the Syracuse RMED program. These
programs continue to challenge students by placing them in roles of
responsibility earlier. Also, I have a concern regarding those who are
undecided. Do we really want students and residents in family medicine that
get there by default or do not want to serve and truly be family
physicians? I, myself, was a late decider, but this was more a function of
a really bad primary care environment and a lack of exposure, since my role
models were all FPs.
About transitional years - For specialists, medical school is a
transitional program. Students in some specialties have to decide early in
order to get in. Only in primary care can students wait and wait and be
undecided so long and still get in, as many of us will find out in just a
few more days.
A Primary Care Focus has some great advantages:
Studies by Jack Verby on RPAP students demonstrated that students in the
M-3 year were overwhelmed by primary care at 3 months, neutral at 6 months,
and did not want to leave primary care at 9 months. The usual medical
school curriculum is only a few months in length at best, just enough to
overwhelm most students. Given more primary care training, it is possible
that more would embrace primary care. Not just awareness or tolerance or
best choice for their life situation or the economic situation, but
actually embracing it.
What if we reversed the current situation of dependence on
specialty-oriented medical schools for primary care residents? What if all
students had to complete primary care medical school/residency in 6 or 7
years and then practice before going back to specialize?
It is certain that we would have people leaving primary care for specialty
careers over time, but we would end the primary care shortage, go a long
way toward recognition of primary care as a valid entity, and ensure that
future specialists at least knew how to work with primary care physicians.
It would also make it more difficult for those wanting mercenary rewards
from medicine. Specialists would be respected more, and so would primary
care physicians. Churchill was right when he said that Americans can be
counted on to do the right thing, after we have exhausted all other
possibilities.
If primary care became the common language of medicine, instead of the
current dependence on a mix of specialty care, we would have far better
communication with patients and doctors from all specialties. Training in
primary care naturally forces training in doctor-patient communication and
training in relationships and culture and the biopsychosocial side. These
are all areas that established medicine has put off for centuries. When
medical schools only pick the students that are the least trouble to
educate, even though they are the least likely to serve the underserved,
then this is another reason for change.
What if we did primary care primarily instead of patching it in?
It was suggested that we add more clinical experiences in the early years.
Response: We do so much of this in the M-1 year now that students in th M-2
year are bored and ready to move on. They are limited only by the fact that
many of our preceptors don't know how much they have already done or the
preceptors are not willing to let them do much. Our M-1 Integration to
Clinical Experience in Nebraska is one of our highest rated courses and M-2
ICE, previously highly rated, has dropped to one of the lowest. When our
faculty began this training, they were not popular with students and
faculty. Now they hold responsible positions of leadership and students
turn to them regularly for advice and assistance, but we are limited in
contact, curriculum, and clinical responsibility. Our M-3 rural family
medicine rotation is one of the highest rated rotations because students
get to participate instead of sitting back and observing at the med center.
When students can learn more in almost any environment except the medical
school (internet, notes, board studies, rural, service-learning,
international) it is time to drastically change the way medical schools
operate.