Subject: Re: Federal improvement for Rural Health
There are several programs around the country that are offering rural fellowships to better prepare family practice residents for rural practice. One of the problems with offering fellowships is that there is no IME/DME for family practice residents once they have completed their initial 3 years of training. In our fellowship program, the fellows don't even come close to paying for themselves and so we depend on the altruism of the institution to keep the program going. Some support would be appreciated. Theoretically, better prepared graduates mean better retention. With some outside support, more programs might be interested in providing additional training. Jim Stageman
I agree with the Fellowship issue. I just discussed MAHEC's short lived rural fellowship with Suzanne Landis and Jackie Hallum. In the four years, they graduated seven fellows, all of whom are practicing in the rural NC practices they worked with during their fellowship. It appears that at least six of the seven are very satisfied, which had not been their experience with many doctors practicing in these sites previously. Different from some of the other fellowships, this one was very strong on community transitional issues and less focused on the procedural issues that are more commonly issues in Midwest, Southwest and Northwest.
However, their business plan was built on GME funding. When that was cut, they sadly had to wind down what appears to be one of the most successful models in the Southeast.
Emily Bray
Rural Director
Department of Family Medicine
Brody School of Medicine at East Carolina University
600 Moye Blvd.
Greenville, NC 27858
252-816-5517
My answer:
One of the challenges is making it worthwhile for anyone to take a 4th year of
graduate training. There are many reasons to do a fellowship
1. Flexibility, self-determination
2. Potential to enhance scope, income
3. Preparation for a specific career, location
4. Intellectual challenge
5. Academics
Tend to see more of those interested in 1, 2, 3 in rural fellowships and not so
much 4 and 5
Our 4th year finale for the accelerated rural training program (3 yrs med sch, 3
yrs fp res, 1 yr rural fell) consists of a somewhat set series of months of
anesthesia, neonatal, ob, scopes, surgery. Since they already know where they
are going to practice in Nebraska, they often do surgery with the surgeons that
they will use for referrals.
The moonlighting that they do is also a big component of their training and
income.
At the Department of FM we set up a separate MBA track, and a separate inner
city track, not much overlap in those interested in each of the three.
Rural administrators are likely to tell you that administration is important,
but finding residents or those in practice who are interested in doing such a
fellowship may be difficult, If you do get some people interested, they might
not be the productive enthusiastic types that help a fellowship get and stay
financially viable, as in Tacoma, Memphis, and other locations. They might be
more interested in career change or might be burned out on clinical medicine, a
concern if you need clinical activities and a good clinical role model for
others at your program, particularly those who fund the program.
Volume OB in particular is a good financial point. Bill Rodney may comment on
this and help you with his article in this area.
The best help that Jim Stageman got at Nebraska in getting procedural rotations
was from those docs (academic and non-academic) who had some sort of rural
connection. They were either from a rural community, had family in rural areas,
or had been in rural practice. I think that they understand the need and buy in
and work well with fellows. Some have done fairly well in terms of time and
finances by working with the fellows. Getting this part up an going is a
constant job, a bit easier a few years later, but the recruitment and strength
of the fellowship is finding teachers who will teach and let fellows do things.
Not having a full year's worth of fellows to promise a potential faculty can
slow things up. Since most of the larger programs have 4 or 5, this allows a
spot to have a fellow 10 or 12 months of the year. This was harder in smaller
fellowship program with 1 or 2. These tend to have more rural continuity models.
VA hospitals, particularly the surgical depts, were good to work with regarding
scope training.
We had a debate today with some faculty over whether things like professionalism
and leadership could be trained or whether they were best experienced. Our bias
was mostly experiential over didactic, because it was application. Granted some
of the concepts could be fed, but no assurance the learner was ready or that the
teacher was as relevant for this particular need at that particular time.
Another way to put it is that your learners will not be comfortable moving on to
relationships with practice, community, etc until they have mastered medicine
and feel comfortable with it. Until this point is reached, they will defer other
learning until they are medically competent. The accelerated program is nice for
this in that it accelerates decision making a year or more, by the 3rd or 4th
year, they are dying to look at these other concepts such as practice
management, the relationship of physicians to state, association, community,
etc.
1. Provide hands-on decision making ops for students, residents, and especially
fellows
2. Give them good role models
3. Give them time in actual practice settings
Oh, better pick mature folks with good medical skills already or they will spend
the year gaining medical skills and miss out on the purpose of the fellowship.
Finally, you are going to work personally with rural administrators. Continue
this with rural visits to them and docs and others at their locations. Rural
folks do not work well over the phone or electronically, especially if you want
them to do something for you. You must do visits. Here is my model for this:
http://www.unmc.edu/Community/ruralmeded/facil/research/authors/Hobbs_Invisible.htm
See copied emails above for others who might have comments
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.ruralmedicaleducation.org or
http://www.unmc.edu/Community/ruralmeded/
Recent list serve postings at
http://www.unmc.edu/Community/ruralmeded/member/rme_recent_list_serve_postings.htm
More at Rural Fellowships