Purpose: These documents will assist students and residents who plan rural practice as well as those who train them - faculty, preceptors, and people in rural communities.
Concerns: Family and general practitioners provide most of the health care in rural America. Rural physicians are aging and some are leaving the demands of rural practice. Their communities need replacements. Younger rural physicians would like to expand their practices, but have trouble attracting partners. Often they find their communities unorganized and outdated regarding recruitment and retention. About 25% of rural physicians plan to leave rural practice in the next 5 years (kindig). The number of family practice residency graduates that choose rural practice continues to remain at 600 - 700 a year, while urban numbers dramatically climb.
Barriers continue to impede the pathway to a rural practice. Myths and misinformation about rural practice, rural training, rural lifestyle, and rural communities abound. Other barriers are in the preparation for a career in primary care. Why a Preceptorship Is Better Many do not access specific training experiences that would prepare them for rural practice. The barriers continue in rural practice where communities can be poorly organized to recruit and retain providers. The following documents are able to assist those who are considering a career in rural health and those who plan to assist them.
For those who are new to rural health, it is important to separate health from the multiple overlapping components of rural life. For those more experienced, consideration of the various components is likely to lead to new insights and approaches. The following are recommended for your review. Eventually this will become a course of study for those truly interested in rural medical education.
For overview information on Rural Medical Education, turn to the WORLD ORGANISATION OF FAMILY DOCTORS
National Rural Health Association Issue Paper http://www.nrharural.org/dc/issuepapers/ipaper13.html
Why doctors do go to small towns
You cannot separate education, the economy, and health care. Click the General Rural Topics for other items of interest involving rural health, rural economics, and rural education:
Family Physicians continue to be the hope for the nation's rural communities
Continuing Family Medicine's Unique Contribution to Rural Health Care
Will the growth of PA and NP Programs impact primary care programs such as Family Medicine Training?
Clearly too many practitioners can be a detriment to the nation. Attempts to produce more physicians have not resulted in more physicians trickling down to underserved rural communities. The major problem is not enough well trained practitioners. The solution is to pick those most likely to go and stay in rural communities and train them specifically for rural practice.
Small Colleges and Pre-Professional Training
Rural Community College Initiative http://www.mdcinc.org/rcci/
Nebraska RHOP and RHEN Programs http://www.unmc.edu/AlliedHealth/rural.html
Native American info http://www.hanksville.org/NAresources/
Medical Schools and Rural Graduation Rates
Premedical
Admissions
Predoctoral programs
Primary care experiences and training -
Rural experiences
Community involvement
Tools for Community-Oriented Primary Care: A Process for Linking Practice and Community Data Presentations In Rural Health
West Virginia http://ruralnet.marshall.edu/
PREPARE - setting up a rural student interest group
Rural Student Interest Group Site http://www.med.ucalgary.ca/education/umeonly/rmig/center.html
Resources for those interested in rural Family Practice include:
Rural Physician Spousal Network, Alberta http://www.rpap.ab.ca/spousalnetwork/index.htm
How rural is the program?
Track record of the program for graduating rural docs (see Listings of graduate programs.)
Special opportunities for procedures, care of underserved, faculty
Moonlighting
Rotations and ambulatory programs
Fellowships
Rural training tracks
Rural practice selection assistance
Rural practice management
Graduate Program Funding http://www.nrharural.org/dc/issuepapers/ipaper1.html
Maturation - the ability to adapt self and skills to situations and people
Concept of medicine, what does it mean to be a doctor, what do I want in a career
Relationships with peers, who is a peer?, health care teams
Interactions with the community
Considerations of the rural difference
The people
The health resources
Structure and function in rural communities
Choosing a community and managing a rural practice (a supplement for residents to use together with the academy's practice management handbook - some of this information is contained in the "You can make a difference" booklet which is excellent, but it can be revised and coordinated with other booklets over the next year)
Peers, faculty advisors, barriers, moving into uncharted territory, taking the personal plunge or following a calling to be of service, following a desire to make a difference
Self assessment algorithm
What type of rural physician are you - community-oriented, procedural, financial, control
Additional careers in rural health
Types of rural practices and rural communities
Overcoming the barriers to a successful search
Coordinating the search
Facilitating your search
The formal interview
The "informal" interview
financing
personnel
consultation
Prior or prolonged contact before a decision rather than a hasty few days and making a decision, practice ownership, have family and kids, community involvement, appreciated by the community, participation in teaching, 2 or less nights a week on call, 50 or more hours working a week. Retention is NOT INCOME RELATED
Principles
Networks tie rural communities to academic networks (Nebraska Rural Health Education Network). State health departments fulfill this function with special branches such as Offices of Rural Health. AHECs provide educational assistance in many states. Rural High School Career Fairs, College premedical programs, special admissions programs for rural background students, and assistance to practitioners are just a few programs. Other examples follow:
Wisconsin Office of Rural Health offers facilitated placement
Iowa Office of Community Based - helps search and practice management
Oklahoma Practice plan developed during residency
N. Carolina 25 employees in an Office of Rural Health to help prepare, select, organize, and maximize a rural practice
Mississippi Department of Family Practice - Ronnie Boyd, an administrator at the program, assists residents and communities with physician placement using noon conferences and dinners as well as site visits and electives.
National Health Service Corps Fellowships offer a chance for rotations as well as community involvement such as community-oriented primary care projects. Students who make connections with communities can experience the rural difference.
Recruitment and Retention of rural physicians States and communities must continually work to keep rural interest high and anticipate barriers to recruitment and retention. Smaller rural communities can not afford to ever stop recruiting.
Recruiting New Rural Practitioners
State programs to increase numbers from rural backgrounds - some effect in increasing the numbers in rural practice, but no need to ignore urbans, especially those with true primary care interest. Half of current rural physicians came from rural backgrounds and half from urban. Only 6% of allopathic physicians (graduating in early 80's) chose rural practice.
Medical education barriers to primary care needing the assistance of
organized medicine/ legislatures
Not enough primary care experience - LCME
Not enough primary care experience - RRC
GME funding prioritizing specialty and hospital based education
NIH funding for research distorting medical school priorities
Increasing pc graduate numbers may not solve rural shortages
New threats from new sources who again say there are too many docs
Bridging from training to recruitment
Scholarships - state,private school, and nhsc
Loan forgiveness and repayment - Multiple types fairly available in most states
Taxes and tax deductions
Oregon
Tracking physicians and their spouses
Awareness of state problems - reimbursement, med practice act
Appropriate targeting of shortage areas - able to support physicians
Choosing areas that can and will support doctors
Developing cooperation between and within rural communities
A final resort - Must we require physicians to do primary care for 4 years after training before subspecialization?
Booklet 1 - the making of a rural physician
The training
advising
the personal development
interpersonal
leadership
management
the curricula
interactions and relationships - the keys to success
The preparation for rural practice
(FP is the way to go, characteristics of training that are important, rural curriculum, and rural programs)
Family practice is the training that prepares physicians best for rural practice. Family practice has the breadth, the ambulatory training, and the integration of the biomedical and behavioral to meet the challenges. Rural practice demands training in gynecology, adolescent medicine, geriatrics, orthopedics, and other areas that different primary care disciplines bypass. Family practice residents train in these areas plus community medicine, occupational medicine, and more. FP residents have the opportunity to tailor their own training by using three to six months of electives to prepare for eventual practice needs and activities.
The challenge of rural practice requires efficient use of all of the seven years of medical education. During their training residents need to be aggressive to assume direct patient care responsibilities and do procedures first hand. This "hands-on" method develops skills as well as the judgment needed to utilize the skills wisely. Superior rural training involves "hands-on" supervision that facilitates resident development without impeding progress. This requires faculty that prioritize teaching and quality patient care. Research and grants are
still important to family medicine, but these academic efforts for family practice faculty derive from the need to care for patients and teach more effectively.
The preparation for rural practice is not so much the development of a knowledge base in all areas as it is knowing one's own limits and how to utilize resources. Careful choice of electives and moonlighting opportunities can facilitate the development of this process.
Those who wish to face the challenges of working with people rather than diseases should choose rural practice. Rural physicians working with groups as well as individuals. Working with families, managing small groups, and participating in meetings are important.
A major difference of rural vs urban practice is the relationship with the community. The bond of a rural physician with a community is special. Rural communities are a more clearly defined population and physicians have a key role in the health of the community. Rural
physicians do public health, act as members of school and health and hospital boards, talk to groups, and help encourage education and service to others. Physicians in small towns are respected and loved. They see the children that they have delivered or cared for grow up. They care for respected town citizens in their last days. Rural physicians who have left their practices often note severe depression. The loss of a rural community and patients can be as traumatic as the loss of a spouse. It is hard to replace the appreciation of a small town. Physicians at the end of their medical careers often consider the years of rural practice to be the ones when they felt most like a physician. Another challenge facing rural physicians is growing up. Too often maturation is delayed while college, medical school, and residency training dominate lives and families. Training physicians have many life decisions made for them. Their daily and monthly schedules, their patient loads, and their peer relationships are shaped by others during training. Their personal finances have also been dictated to them in most cases. Those who choose rural practice need to make good decisions regarding personnel, choosing a house, budgets, selecting community contacts, and more. They need to be aware of community customs, traditions, and leaders.
The environment of rural practice is quite different from that of medical training. Students and residents relish their free speech. At the mercy of medical education, they will justifiably complain and critique. In rural practice these same complaints and critiques may have more consequences. As rural physicians they have more choices and more control. Young rural physicians may not realize that situations are the result of their own choices, rather than those of administrators or others. In their enthusiasm for change or new programs, they may fail to include key town leaders who may react negatively to such efforts. As leaders in small towns, physicians will face challenges and sometimes fail. It is a defect of our time that we hear more about these failures than those who quietly succeed. Young rural physicians do learn and grow, however, and they make major contributions to the health and welfare of their towns. Those in medical training may never realize the rewards that await them in small towns.
Rural physicians provide much for small towns. Rural physicians employ three or four employees directly and their economic activity supports another dozen or more jobs in a rural community. In addition physicians are essential for hospital and emergency services. Small towns cannot keep or attract new jobs without adequate physician services. The smaller size makes it more difficult to continue to address all of the components of the community such as education, safety, transportation, meaningful work, leadership, government, and communication. Rural physicians work with administrators, public servants, community organizations, boards of education and others to address these areas.
A rural faculty advisor can be a major help for those planning a rural career. These faculty have often been rural physicians. Faculty advisors should meet regularly with trainees to assess their progress in clinical, interpersonal, management, and personal areas. Rural practice is a challenge and faculty may need to push residents and students to face areas of weakness in order for them to consider rural practice. Rural faculty advisors may do more to enhance rural recruitment and retention than any program. They know other faculty and programs across the nation who can meet the growing needs of students interested in rural health. Residents or students without rural faculty or practitioners to advise them can utilize a network of rural faculty developed by the STFM Group on Rural Health. (see page )
Programs who prepare residents for rural practice must address the following areas of curricula:
Rural physicians noted the following that would help them prepare for rural practice:
(Tom Norris info here from national surveys of rural physicians)
Methods
The primary method of accomplishing the above goals and objectives is a series of significant rural experiences during training. Most important are experiences actually in rural communities. Other "rural" experiences occur at talks and discussions by rural faculty and rural physicians. Only by comparing different rural experiences in person or through others will students understand the opportunities that await them in rural practice. Too often a single experience shapes career goals.
The second important area of concern is facilitating the rural experience. Students sent cold into a rural situation are not ready. They need to have a few days of preparation to acculturate them. They need to know something about rural communities and the people they will meet. The Appalachian Preceptorship begins with five days of examination of the doctor-patient relationship, alternative health beliefs, the role of the physician in the community, and the cultural strengths of rural people and the things they value - relationships, recreational activities, etc. The history and traditions also highlight these strengths as well as some of the weaknesses.
Once trainees go on location, the next task is making them feel welcome and involved. Rural communities offer a chance to belong. The ability to communicate this may do much to enhance future recruitment into a rural practice. A good orientation to the clinic, hospital, physicians, and other health professionals is necessary. Each community has a few individuals who are skilled in making newcomers feel welcome. Local rural physicians should take care to identify these individuals so that trainees may become involved in community life through family, church, or community activities or events. The AMSA HPDP program prioritizes this involvement with a community health project. Students work with community leaders and get involved in the community. They see both strengths and weaknesses. Once students become comfortable with being involved, they are more likely to choose more intimate practice situations. Recent studies by Pathman on rural retention revealed that rural physicians noted a more positive impact in a rural experience when they felt involved.
Rural practice is a challenge. The seven years of training must include "hands-on" training in procedures and patient management where the student or resident is allowed to bear an appropriate and ever increasing amount of responsibility for patient outcome.
Just as important as clinical confidence, is the maturation of the student as a person. Medicine has a way of focusing a person inward toward the prioritization of personal goals such as knowledge. Third year students disappear from family, friends, student organizations, and church participation. It is more than coincidental that these choices occur at a time when interest in primary care and rural practice dip sharply. Older students often choose family medicine, perhaps because they kept their focus and they had had to make many tough (and learning) decisions in order to get into medical school.
Physicians must also learn to serve others and balance their own needs against those of others. Subspecialty practices distance patients and physicians through assistants and technology. Primary care and rural practices cannot avoid dealing with patients resources whether they are social, financial, spiritual, or other. Students given the opportunity for rural experiences often get away from the impersonal training environment. They see the value of the doctor patient relationship.
Physicians must also work on health care teams. In rural communities where resources can be short and multi-skilled individuals are the norm, the person who can best be of service can come forward. Physicians who prefer to work alone can become isolated.
More here to come from Georgia work and University of South Alabama work.
Faculty should assess, supervise, advise, give feedback, and facilitate these efforts by students and residents.
Booklet 2 - Rural medical education - a continuous and integrated series of experiences
Premedical
Admissions
Continuing rural interest - Predoctoral programs
Addressing barriers
Choosing the rural pathway
Primary care experiences and training
Rural experiences
Advisory resources
The beginnings of rural practice - premedical programs
The beginnings of rural practice are in the premedical school preparation. The earliest beginnings are in the examples set by primary care physicians as they care for young patients or children in schools or their neighborhoods. Many programs prioritize science or math development, but the early impressions of children are not technical skills, but relationships and attitudes of caring and confidence. The emphasis on the selection of medical students based on their development of knowledge and technical skills has certainly produced a tremendous knowledge and technical base for medicine, but these advances paved the way for the need for physicians who relate to people and to each other. This is the basis of family medicine and primary care. Rural practice in particular demands individuals who have skills in the biomedical and social science areas.
It is clear that policies that have increased the numbers of medical students without prioritizing primary care have been responsible for our current health care crisis. Few if any more subspecialists are needed. Current proposals to increase the numbers of primary care physicians seem to be based on the same "trickle down" theory. There is no guarantee that increasing primary care physicians will address the health needs of rural America.
It is important to remember that half of rural physicians come from rural communities, the other half come from urban areas. Programs which select rural background candidates have been somewhat successful in increasing the yield of rural physicians. Other programs target primary care and family practice interest. More work needs to be done on early identification of those likely to choose rural practice, especially those from urban backgrounds.
Many studies highlight the importance of selecting medical school candidates based on their likelihood of choosing rural practice and primary care. Many different premedical programs address this area. Rural Health Career Fairs and summer health experiences are one means of extending the possibility of medicine to rural high school students. AHECS, FP Departments, and medical student groups sponsor these efforts. FP speakers interact at college pre-med groups. The Washington State Academy of FP has a faculty, physician, or resident contact for every school in the state. These contacts can improve the career counseling, highlight college preparation, and extend the rural physician pipeline to gather those more likely to choose rural.
Continuing Rural Interest in Medical School
Once admitted to medical school, the job has barely begun. The loss of primary care and rural interest during medical school is staggering. Most students begin training with primary care goals, only to bow to other pressures or interests as the years pass. Medical students who do not shape their own careers may find themselves following the subspecialty influences of faculty, facilities, and fellow students.
Students should take note that medicine is changing rapidly. Those who graduate as subspecialists in five to ten years may face increasing limitations on hospital and procedural care, competition from established as well as new subspecialists, and restrictions on subspecialty care through managed care systems and governmental reforms. These factors should weigh heavily on the career decisions of today's students.
Barriers to Rural Practice
The media of today highlight many of the problems facing rural America. Every plant closing, every shocking crime, every facet of rural life is examined and often condemned. Medical "journals" such as Medical Economics thrive on negative stories. Many of these are about rural practice. Over 400 family practice faculty have been in rural practice. Each of these faculty members has good and bad stories to tell about their experiences. Some of them have recently left practices and still are dealing with this loss. Students sometimes contact rural physicians and form impressions regarding the isolation, not realizing that isolation is mostly a function of the physicians own personality and his or her relationships with others. As students circulate through the "Hallowed Halls" of institutional medicine they hear stories about local physicians who "messed up" by trying to take care of the more difficult cases. Studies reveal that patients in these academic centers are one in a thousand, the rarest of the rare. These cases are a poor reflection of primary care practices. Such encounters may be used to reinforce the need to know everything. Students can become overwhelmed and choose subspecialty careers.
Many students are still told that they are "wasting their lives in family medicine or rural practice" by faculty or their fellow students. Students must examine primary care and rural experiences on their own. The same "situations" may seem very different when seen first hand. Neurosurgery is taught by neurosurgeons and rural practice needs to be taught the same way. Faculty must work to change the environment in favor of primary care and rural practice. Curricular time with enthusiastic primary care advocates is important. Student groups can emphasize primary care and rural experiences, deal with the myths and mistruths of rural practice, and encourage faculty advisement.
The rural practice environment is changing rapidly. A common myth is the isolation of rural practice. Nearly all rural hospitals have subspecialty staff or clinics on a regular basis. More and more rural physicians are part of satellites, groups, or systems of care. Maps of these connections in rural states reveal few areas that do not have such contact. The phone has always connected rural physicians to consultants. Computers and telecommunications continue to enhance these connections. Rural practice in the year 2000 will be a bit different than the images we still hold of 1900 horse and buggy medicine.
Choosing the Rural Pathway
Students who wish to examine rural practice must take a different pathway. This pathway should include primary care and rural training experiences, top-notch medical education, procedural training, and rural faculty advisement. Career choices are not a single decision, but a whole series of decisions made during the seven years of training. One preceptorship, one faculty advisor, or one conference may not be enough. Students interested in rural health must pursue the advisement and experiences that will shape a career in rural health.
Some rural experiences are open to medical students from across the nation. The National Health Service Corps Health Promotion and Disease Prevention project administered by the American Medical Student Association is a six to eight week elective for first or second year students. Students work with patients, rural physicians, Community Health Centers, and community leaders. Each of this year's incoming 240 medical students will do a community health project. Over 80% of the 470 student graduates of this program have chosen primary care and 33 of 43 are currently serving the underserved. The Appalachian Preceptorship at East Tennessee State University invites students at all levels to share a rich rural practice experience for a month. Twelve students meet with faculty to discuss the impact of culture on health, the doctor-patient relationship, the role of the rural physician in the community, and more. Students recreate together and support each other during medical training. Students may choose to create electives by talking to clinician-faculty such as Sandral Hullett, M.D., at Eutaw, Alabama at one of several Community Health Center sites. This practice has trained medical students and students in five other disciplines. Students going to the site are impressed with the devotion of the physicians and staff. This role modeling is often a key component of a good rural experience.
Students who hope to maintain and develop interest in rural practice can form a rural student interest group. The North Carolina Student Rural Health Coalition in North Carolina has chapters at Chapel Hill, Duke, and East Carolina. NC students work with rural communities to deliver primary care at monthly clinics under the supervision of local practitioners or faculty. Students also assist with health fairs. The Rural Student Interest Group at East Tennessee State University organizes an annual career fair for rural high school students. Family practice student interest groups, AMSA groups, Christian Medical and Dental Society chapters, and SNMA groups also sponsor rural activities. Students realize the need to learn to work with rural communities. They also plan to attract practitioners who will join them later in rural practice.
A successful rural program addresses the needs of health professions students at all levels. No state or medical school can afford to pay for such a program. Three other resources make these programs possible: students, rural communities, and health organizations.
The efforts of students as individuals or organizations is paramount. Students have enthusiasm, they have a great desire to serve, they need experience. Rural or family practice student interest groups can do much to address the needs of a rural program. Medical and other health care students can talk to high school students, organize health career fairs, and do health fairs for rural communities.
Rural communities have a vested interest in the development of rural programs. They need to prepare and encourage their students to become health professionals. They should support students and residents who stay in their commuity for training, interviews, or visits. Nebraska rural communities provide over $200,000 a year in support of various students during training. Rural communities need to do a better job to involve trainees. They also need to organize, communicate, and recruit better so that more trainees with rural interest can get this information and choose a rural practice. Rural communities are the magnet which draw students at all levels toward the final goal of a rural practice.
Organizations with rural interest do much to facilitate the decisions of trainees. The Texas Academy of Family Physicians sponsors the statewide preceptorship program. Many academies assist residents with the search process. Others sponsor health career activities and advisement. Rural health organizations hold conferences and help sponsor rural practice information. Primary Care organizations and state health departments can help bridge the gap between training and practice by facilitating the search process by career fairs, recruitment dinners, and keeping current information on practice opportunities.
The first major step to rural practice is the choice of a rural-oriented family practice residency. These can be identified by discussions with faculty or advisors, referring to the AAFP Directory of Family Practice Residency Programs for programs with a rural emphasis, choosing a community-based residency in a smaller town, or taking a rural training track. Students should verify a rural-oriented program by talking with faculty and residents. They should ask for details about the curricula, the rural sites, the faculty, and whether the program produces rural physicians. Programs with a proven track record of producing rural physicians are a good choice.
Special rural training programs exist in the form of rural training tracks and rural fellowships. Rural training tracks begin with a year at urban sites such as Spokane WA, Greeley CO, Omaha NE, Buffalo NY, Hazard KY, Terra Haute IN, Rochester NY, Greenville NC, and Sioux City IA. Residents then spend their last two years in a small town practice. Residents may choose a 6 or 12 month procedural, obstetric, or rural fellowship to supplement their training. Tennessee (ETSU), Maine, New York (Buffalo), Nebraska (UNMC Omaha), and Washington state (Tacoma) have rural fellowships. Residents attending these or other rural oriented programs can access rural rotations, faculty, and information about rural practice.
There are some other important information sources about rural practice. The Society of Teachers of Family Medicine has a Rural Programs Compendium. The annual meeting of the family practice students and residents in Kansas City each August is an excellent opportunity to examine rural programs and talk to rural faculty. The rural presentation at this conferences has been the best attended for the last three years. The National Rural Health Association often assists students interested in rural health.
More work by another author here about current examples
Listings of Premedical programs here
Booklet 3 - Rural graduate training
Principles
Location of the program - how urban is it?
Mission of the program - is it preparation for rural practice?
Faculty - how rural are they?
Program attitude toward primary care, procedures, rural, moonlighting
Characteristics of the residents and their choice of rural over the years
Rural Practice Selection and Practice Management - Does the program assist and support graduates who choose rural practice both during and after residency?
Listings of residency programs with rural emphasis or experiences
Those with rural ambulatory experiences
Longitudinal
Rural continuity practices
Rural training tracks
Block rural rotations
Rural fellowships
Rural Residency Experiences and Programs
The most important step to rural practice is the choice of a rural-oriented family practice residency. These can be identified by discussions with faculty or advisors, referring to the AAFP Directory of Family Practice Residency Programs for programs with a rural emphasis, choosing a community-based residency in a smaller town, or taking a rural training track. Students should verify a rural-oriented program by talking with faculty and residents.
The location and mission of a program may be key.
Students evaluating a program should ask for details about the curricula, the rural sites, the faculty, and whether the program produces rural physicians.
Moonlighting in rural areas is a key preparation for rural practice.
Residents can tell whether they actually get to take care of patients and do procedures. They can also source of information about moonlighting opportunities and policies.
Programs with a proven track record of producing rural physicians are a good choice.
Programs have several types of rural experiences. Some utilize a rural location for all or part of a continuity clinic experience. Others have mandatory rural rotations of one or two months in a rural practice. Optimal rural experiences involve residents in the practice, the community, and the rural lifestyle.
The practice should give residents an opportunity to "be physicians" and stand on their own.
Procedural training is appreciated and can be more available in rural sites. Appropriate supervision and instruction by rural fps or surgeons can enhance the education and the confidence of the trainees.
Community people should work with rural physicians to optimize the experience.
Residents and spouses should attend dinners and community activities. They should be recruited by towns in the area. Feeling wanted and appreciated can do much to influence trainees who can lose touch with their purpose in life.
The preparation for rural practice involves "hands-on" training.
Residents need to take responsibility for patient care. They need faculty who will invest the time to assess them, allow them to work within their expertise, supervise them when they need help, and give them feedback to allow them to move beyond their current limitations. Residents need to direct the care of critical patients, trauma victims, and cardiac emergencies. They need to be competent in many areas such as obstetrics, cardiac testing, endoscopy, colposcopy, and other services needed in rural areas. Rural practice is demanding and the preparation involves the full seven years.
The clinical areas should not be ignored. Residents need to develop true competence as well as self-confidence. The following specific areas have been identified by family practice program directors, most of whom have been in rural practice or have rural programs, as preparation that may be necessary for rural practice (further text to come from previous documents):
Rural Clinical Topics
Advanced Ob-Gyn, ALSO, Neonatal, colposcopy
STFM perinatal page
http://www2.family.mcw.edu/wolk/ob_pres/lib_pg.htmTrauma, ATLS
Critical care, ACLS, PALS
Surgery and procedures, endoscopy
Orthopedics and sports medicine
Practice management for rural practices
Not all rural practices involve emergent care. Some practices are very small or limited to office practice or have covered emergency rooms. In these sites emergent care is few and far between. Preparation is necessary, but panic about the possibilities of getting overwhelmed is unwarranted. Actual studies of rural practices reveal low rates of trauma and cardiac disease. Obstetrics is also related to numbers and patient selection.
Rural training tracks and rural fellowships may assist residents interested in achieving rural goals.
Rural training tracks are special family practice residency programs which utilize the resources of the home site for the first year, then a two year experience in a rural community. The currently approved rural training tracks begin with a year at Spokane WA, Greeley CO, Omaha NE, Buffalo NY, Hazard KY, Terra Haute IN, Rochester NY, Greenville NC, and Sioux City IA. Residents may choose a 6 or 12 month procedural, obstetrics, or rural fellowship to supplement their training. Tennessee (ETSU), Maine, New York (Buffalo), Nebraska (UNMC Omaha), and Washington state (Tacoma) have rural fellowships. Residents attending these programs can access rural rotations, faculty, and information about rural practice.
Using the full three years of the residency is important. Residents who sit back passively, do not learn what is necessary. Electives and experiences can be mapped out with rural faculty and advice from other residents. Residents and their spouses can begin to search for a practice by traveling, doing electives, interviewing, and focusing on the search for practice.
The selection of a practice is a major step. One entire booklet addresses this area. The process starts in residency programs. Practice management training should be specific for rural practice. Faculty advisors or consultants should individualize this training for the resident to meet his or her specific needs.
Sources of Rural Information
There are some other important information sources about rural practice. The Society of Teachers of Family Medicine has a Rural Programs Compendium. The annual meeting of the family practice students and residents in Kansas City each August is an excellent opportunity to examine rural programs and talk to rural faculty. The rural presentation at this conferences has been the best attended for the last three years. The National Rural Health Association often assists students interested in rural health. (see the appendix for contacts, addresses and phone numbers for each of these groups.)
The Choice of a Practice
Residents face many personal challenges when considering rural practice. Medical education takes its toll in time from family and debt. Those considering rural practice need to know about time for family, income, jobs for spouses, and debt repayment. No location, urban or rural, meets all needs. The search for a practice is a courtship that ends up in a marriage with a practice and a community that best fits these needs.
Rural practices are no better or worse than urban. They do not lack culture or recreational opportunities. The opportunities are different and a matter of personal preference. The information about rural communities and practices is often less available, making the search more difficult. In studies of family practice senior residents, residents invest just a few days to search for a location and a practice. After spending half a lifetime to train, such a minimal investment in the search process does not make sense, especially when the search process itself is such a growth experience.
Residents and their spouses can begin to gather information about practices during the early years using the phone, state contacts, rural faculty, and other sources. Residents can plan rotations and moonlighting that give them a chance to visit rural communities. During that visit trainees should gather information to insure that the community can support the physician with the income, call coverage, facilities, and community resources needed. Three or four visits or an on-site elective can be very helpful in examining a location. Residents who have made more detailed searches of rural communities feel that the the existence of an active recruitment and retention committee is important. Rural communities should never ever stop looking for physicians. Physicians can and should choose sites with a future, not those who are most desperate. Residents who begin a search late can do locum tenens work or a fellowship and use the year to examine more rural practice opportunities.
Residents interested in rural practice should take advantage of multiple opportunities for financing. Hospitals, communities, practices, and governments can arrange a variety of packages to assist in establishing a practice and repaying debts. The NHSC loan repayment is a gold standard that many others hope to approach. Residents apply in their final year and can receive the following funds in exchange for service: 2 years brings $50,000, 3 years $85,000, and 4 years up to $120,000. The NHSC also pays up to an additional 39% of this figure for taxes as loan repayments are considered income. (info as of 5/93) Many states or community groups come close to these figures and some include practice startup funds or bonuses of up to $25,000.
Those who wish to face the challenges of working with people rather than diseases should choose rural practice. The bond of a rural physician with a commuity is a special appreciation of one for another. Often the significance of this bond is not felt until it is broken. Rural physicians who have left their practices often note severe depression. The loss of a rural community and patients can equal or exceed the trauma of the loss of a spouse. It is hard to replace the loss of a small town. Physicians at the end of their medical careers often consider the years of rural practice to be the ones when they felt most like a physician.
Just as their are a variety of locations and practice types in rural health, there are additional opportunities for rural physicians. Rural practice is often not the only physician activity in small towns. Other possibilities include teaching, clinic direction, group involvement, emergency services, and working on rural health systems:
Teaching - The increases in the use of rural practices by medical education affords more academic connections. Many rural physicians now have their cake (rural practice) and eat it too as part time teaching affords contact with other faculty, residents, and students. Teaching has been noted to be a factor in retention of rural physicians. Rural practice is a great source of research ideas. The challenges of rural practice have led many leaders in family medicine to initiate studies in behavioral medicine, the doctor-patient relationship, addictionology, practice management, medical education, and health policy and planning while still in their rural practices. Others participate in research networks involving the delivery of primary care.
Clinic direction is another possibility. Rural physicians can manage their own practice or direct care in nursing homes or community health centers. Others work with hospitals on outpatient activities.
Management and leadership - The rural hospital is another opportunity for development of management and leadership skills. Committees and boars in rural hospitals are small and need the active participation of doctors. It is not uncommon to be a chief of staff within two or three years. With a small number of doctors, the needs of each must be met so that the hospital can meet its mission and maintain function. Rural physicians also are important to the recruitment of new physicians for the area.
Public health - Rural physicians often direct public health, EMS, disaster preparation, emergency care, and other such operations.
Community organizing - Physicians with a desire to organize community groups can serve on school boards, the chamber of commerce, or establish non-profit organizations to meet the needs of patients or the community. Many rural physicians participate in economic development programs, realizing that getting and keeping jobs is linked to their practice vitality.
Health planning - Other physicians work with governments and facilities on health systems planning, or work with the legislature. They often utilize their state family practice academies to meet these goals.
Mental health direction involves many rural physicians. Some take additional training in family issues and counseling for these roles.
Rural practice offers many opportunities to broaden careers.
Listings of contacts for practice search
Compass, Federal programs, etc.
Booklet 5 - Rural communities and rural medical education (for communities and rural preceptors)
Organized, Community-Responsive Rural Health Systems
A VISION FOR HEALTH REFORM MODELS FOR AMERICA'S RURAL COMMUNITIES http://www.nrharural.org/dc/issuepapers/ipaper11.html
early interest - networks and a state plan such as Nebraska RHEN helpful
bridging programs -
Most state health departments and fp associations track openings
AHECs in some states such as Wisconsin Office of Rural Health offer facilitated placement
Iowa Office of Community Based - helps search and practice management
Oklahoma practice plan developed during residency
N. Carolina 25 employees in an Office of Rural Health to help prepare, select, organize, and maximize a rural practice
Mississippi Department of Family Practice - Ronnie Boyd, physician placement, dinner or noon, 14 site visits, 25, 32, 23, and 1993 16 so far 93 on file 1990 1/10, 1991 3/9, 1992 12/13 in rural underserved MS, outcomes - incr info, incr rural rotations, incr educ of community, incr network, poss incr # in rural, incr knowledge of state of rural health
Helping medical education programs to develop the local curricula - learning connectedness
community involvement may be most important
Recruiting physicians - rural communities must send qualified students and encourage the training of students and residents at their location. Most rural communities should never stop recruiting doctors, ever!
Retention of rural physicians - must keep track of them and their spouse after recruitment, assist their development, help them address problems, help them get involved
Booklet 6 - Health policy to produce and retain rural physicians (for all)
State programs to increase numbers from rural backgrounds - some effect in increasing the numbers in rural practice, but no need to ignore urbans, especially those with true primary care interest. Half of current rural physicians came from rural backgrounds and half from urban. Only 6% of allopathic physicians (graduating in early 80's) chose rural practice. 25% of population rural and may be increasing slightly. Only 17% of total doctors rural. Two thousand shortage areas and growing. Gap occuring as older gp and fp out and not enough moving in to rural.
Rural Physician Spousal Network, Alberta http://www.rpap.ab.ca/spousalnetwork/index.htm
Medical education barriers to primary care needing the assistance of organized medicine/ legislatures
Not enough primary care experience - LCME
Not enough primary care experience - RRC
GME funding prioritizing specialty and hospital based education
NIH funding for research distorting medical school priorities
Increasing primary care graduate numbers may not solve rural shortages
New threats from new sources who again say there are too many doctors
Bridging from training to recruitment
Scholarships - state,private school, and nhsc
Loan forgiveness and repayment - Multiple types fairly available in most states
Taxes and tax deductions
Oregon
NHSC pays up to 31%extra to cover taxes
Courtship rather than contract
Retention programs
Impacting on training
Tracking physicians and their spouses
Awareness of state problems - reimbursement, med practice act
Appropriate targeting of shortage areas - able to support physicians
choosing areas that can and will support doctors
Developing cooperation between and within rural communities
A final resort - Must we require physicians to do primary care for 4 years after training before subspecialization?
The Current State of Rural Primary Care
The pipeline to rural practice involves personal, clinical, and professional development over many years. The current situation could hardly be made worse for the production of rural physicians. The urban-based living for long training years, the lack of information on decisions that would lead to rural practice, and the multiple transitions make this a difficult process. Despite much rhetoric, few medical schools or residencies truly prioritize primary care, much less rural practice. Only 47 of 125 have primary care in their mission statements and only 24 require some form of rural experience. As schools have depended more and more on subspecialty and research faculty to improve their financial picture, rural interests have lost out. Most schools have few rural faculty or programs. Students with rural interest are mostly on their own.
The pipeline is a long, extending across several years and several locations. Family practice and family physicians have been the major contributors in this area. FP Faculty have developed nearly all of the rural training programs. Most of these are limited in scope. Few of these programs have been replicated and many new programs start out on their own, without the benefit of others experience. The following are estimates of the impact of rural programs on the medical education process. So far the total impact has not been great.
At the medical school level there are a few programs to facilitate admissions of those with rural background impacting on perhaps 1% of 16000 entering students. More programs seek to encourage students with service commitments to the underserved. Perhaps 5%of students have such obligations. The past has brought major declines in rural interest over the years of medical school and residency down to as few as 13% of medical school seniors showing interest in rural practice. Prioritizing rural students ignores the source of half of the nation's rural physicians, urban background medical students. Little is known about why these students choose rural practice. Is it community-orientation, altruism, a calling, or something else? More work needs to be done in this area, but the pipeline is so long that it is difficult to tell the impact of programs that must wait for 7 - 10 years to measure rural outcome. Dealing with human decision-making is a difficult process and controlled studies are next to impossible. Admissions programs are a good start toward the production of rural physicians.
The environment of nearly all medical schools is not good for primary care and rural medicine as the training is urban, tertiary, hospital, subspecialty, and research-oriented by faculty composition, by curricula, by leadership, and by mission. According to a recent review of mission statements by the AMA, only 47 of 125 allopathic medical schools mention primary care. A big debate surrounds the creation of family practice departments at all medical schools. Some fear that medical schools without primary care as a mission will waste the efforts of family practice leadership and exceed the available supply of fp faculty. Others feel that family practice needs a presence at all campuses. Some feel that more resources should go to programs more oriented to rural practice while others would fund medical school programs that impact on students.
The outlook for rural rotations is a bit brighter as 123/125 allopathic and all osteopathic schools have rural experiences available. Some (24) allopathic medical schools even require such an experience. There has been some slow growth in special rural experiences that last over three months. These usually involve 20 - 30% of the class in a special track. Minnesota's RPAP and Duluth programs, Michigan State's Upper Peninsula program, the New Mexico Primary Care Curriculum, and similar tracks impact on less than 2% of the 16,000 students that graduate each year. Generally over the past twenty years, rural experiences have decreased in length from 8 - 12 wks to 4 - 6 wks. The good news is that further decreases are unlikely in as the climate drifts more toward primary care. Other programs are available to all medical students, usually taken in the summer. These include AMSA's HPDP, PHS programs, and the Appalachian Preceptorship. These impact on 3% of the total medical students with another 6% applying, but not selected.
Accelerated programs act to improve the process by bypassing the senior year and the match. The sooner the decision, the more likely a primary care career. Of the 11 programs, only the Nebraska program has a designation as a specific rural preparatory program. Most skip a year of medical school. Other schools should consider accelerated programs as a means of converting the senior year to a more thorough early rural primary care experience. Others may wish to tack on a 4th year of graduate training as a fellowship.
At the residency level 119/400 fp programs say they have "rural" in the AAFP directory yet few mandate rural experience (total unknown). Rural interested students have few sources of information about rural programs and no information about the ones that actually produce rural doctors - a key item of information for those who plan rural practice. Most disciplines have little rural experience during the 36 months. FP faces major limitations regarding rural training due to size, continuity, subspecialty, and hospital requirements, but it keeps trying through rotations and rural training track programs. A bright spot has been the growth of Rural Training Track programs to 9, currently impacting on 20 - 30 residents a year. FP produces about 1000 rural physicians each year as 42% of 2400 graduates in 1991located in towns of <25000 population.
Major concerns at the residency level include the lack of support for rural faculty and their activities. Most programs are increasing their clinical demands. Universities have few sources of funding for rural faculty. Rural faculty at community-based residencies can contribute only a few hours a week to rural programs.
Rural communities are the final outcome measure for the pipeline to rural practice. The transition from residency to rural community is perhaps the weakest link. Few programs address this most important transition. The lack of reimbursement for rural physicians and declines in many rural economies have made the leap from training to practice more difficult. Rural communities are poor recruiters. Administrators and physicians are busy in other areas. Recruitment of physicians is perceived to be an intermittent need and the efforts are similarly intermittent and haphazard. Some are so desparate that they scare recruits away.
Even worse is the lack of recognition of the problem and potential solutions. Many rural communities blame outside policies or entities for their problems instead of focusing on what they can do with needs assessments and organization. Many rural doctors are not active in the recruitment process. The best efforts are made by teams of community citizens, facility administrators, and health care providers.
Recruitment is but a start. More long term success may come from retention programs, but no one knows as little has been done in this area. Goverments may worsen the process by reducing all health expenditures by percentages. Such methods often punish primary care programs who traditionally have had lower reimbursements and less chance for diversification.
checklist for your rural programs
Challenges for Rural Faculty and Program Directors
The Role of Rural Faculty - Never was the need greater for rural faculty to be able to truly influence medical education yet a recent survey revealed less than 400 family practice faculty doing rural programs on mostly a part time basis. Very little assistance comes from IM and Peds.
What does FP need to be able to address the production/maintenance of rural practitioners at the state level?
First for the assumptions
Most faculty have at least 30% clinical work and 30% teaching of students and residents, the rural work will be done on a part time basis by full and part time FP faculty.
Next for the hard choices -
One person cannot attempt all the tasks that make a successful rural operation. This is impossible. junior faculty can try, but do not know the program or institution. Program directors or chairs have been most successful, but rural duties can force them to neglect other areas. The best choice is several faculty of various experiences working together on the following areas:
Positions located at the Medical School
Assistant/Associate dean position - Guides a state rural task force, works with interdisciplinary programs, coordinates AHEC and family practice and rural grants. Schools supporting these positions recognize the need to train primary care faculty for eventual dean and chancellor positions. Recent searches for deans reveal few if any candidates with primary care backgrounds.
Admissions Committee positions - Several members and a chairman favorable to primary care and rural factors can help likely rural physicians get a start. Some schools utilize rural physicians (WAMI) or rural citizens. Others use primary care and rural interested students. There is a great need to educate faculty, staff, and admissions directors regarding factors for rural and primary care selection. Admissions can also implement any special admissions programs favoring rural or primary care such as those involving students from rural state colleges.
Curriculum committee development - The majority of medical schools are making major revisions of their curricula. These changes offer the opportunity to establish more primary care orientation. Early and integrated primary care experiences may keep students from losing their initial rural and primary care interest. Other committees are pondering longer rural experiences, realizing that comfort with primary care may take more time.
Rural predoctoral programs - Faculty and adequate staff must coordinate rotations, recruit and train part time faculty, assist rural physicians in the development of local curricula, train preceptors, and sponsors family practice and rural student interest groups.
Advisement of students - Students need to know about rural opportunities, electives, rural residencies, rtt, rural fellowships, and rural faculty at other programs. These faculty members also are active in the rural and fp student interest groups, DOC, CMDS, AMSA, and similar groups.
Visitation program - Most if not all department faculty should participate in the rural programs. All should visit rural physicians at their sites. This keeps faculty connected with the reason for their existence and helps them understand the needs of rural towns and their practitioners. These visitations reduce conflicts, clarify information, improve teaching, increase support for rural physicians, and provide support for rural physicians. A recent study by Don Pathman demonstrated teaching as a factor in the retention of physicians.
Rural faculty development - The training of physicians offers little exposure to learning theory, curriculum development, teaching techniques, adult learning methods, and evaluation. Faculty development can address these needs by developing skills in rural physicians. The AAFP Division of Education has materials to assist in this area. The major difficulty is getting rural physicians to attend. A faculty visitation or exchange program may help here. The STFM rural faculty survey revealed another potential solution. More physician-preceptors were interested in giving faculty development than receiving it. Use of rural physicians to teach the faculty development with faculty to coordinate, moderate, and facilitate may be the best solution.
Other rural faculty roles - These can be filled by positions - university, community-based, or volunteer:
Rural residency rotations - Faculty must coordinate rotations, train preceptors, recruit preceptors, apply rural curricula at the local level, work one on one with preceptor, visit and practice in the community or hospital a few days, and have the preceptor in to teach and learn.
Rural fellowships and rural training tracks are new programs that emphasize rural practice preparation. These programs require a true program director as their tasks include recruitment, curriculum development, financial planning, resident advisement, arranging clinic services, and more. A key part of this work is working with faculty who teach procedures, supervise rotations, or precept.
Advisement of residents - Faculty advisors should keep up with resident preparation and progress, push them to moonlight in rural locations and do procedural electives, act as a PHS advisor, assist residents with practice management, use their experience as a former rural physician to identify problems and solutions. Rural faculty can connect residents with state rural and primary care opportunities. Faculty can identify some residents as potential teachers to begin their faculty development prior to leaving residency.
A key role of today's rural faculty is keeping information on rural outcomes. This can be done by university FP, community-based FP, or state FP academy, legislative activity, contacts with rural communities, work with state rural associations and primary care organizations
There is a great need for research to be done in and for rural areas. Primary care research networks can facilitate this goal. Contact
Key liaisons for rural faculty and rural programs
state fp association state health department
state rural health association state primary care association
key state contacts in the following areas
the legislature rural communities - advisory
rural physicians - advisory hospital administrators - advisory
moonlighting opportunities consultants for rural practice
recruitment for rural practice