Those who are interested in rural practice need specific preparation involving the most challenging curricula. Family practice residencies have responded with rural training experiences. Past medical leaders such as Osler, Flexner, and deans at prestigious medical schools for most of the past century have long noted that the best physicians were needed for rural areas. Only in recent years have we forgotten this basic lesson. There is great value in rural training. Students and residents training for longer periods in rural areas have equaled or outpaced their peers in all behavioral, procedural, and cognitive areas examined.

"I believe a large part of the rural physician shortage that exists today is secondary to how medical education has evolved. FP residents training in large medical centers appear to be brainwashed into thinking that they cannot manage cases common to rural practice without specialty consultation. A sense of "helplessness" evolves with delivery room emergencies (retained placenta, postpartum hemorrhage, instrument delivery), neonatal emergencies (resuscitation, sepsis evaluation, hypoglycemia), and other skills needed in rural practice. They are scared away from rural practice. " Jim Damos, MD, Director, Baraboo RTT

You are likely to be the only learners at your hospital. You will not have to compete with other residents for procedures and patient care opportunities. Having rural physicians as faculty means having experienced practitioners (Rural Docs Are Tops) who know what you need to learn to prepare for rural practice. You will be training in a setting that mirrors future rural practice. You will learn about practice management, rural health systems, and the structure and function of rural communities. You will also be serving a rural population in need of health care.

"The day to day work is much more similar to what a rural doctor would experience. I like the idea of working where there is a true need. I like the feeling that if these doctors weren’t here, these services might not be here." Hans Elzinga, MD, RTT graduate

You will be the "front-line physician" in a rural ER or hospital or clinic. You will see interesting cases first with opportunities to build competence and confidence. You will have exposure to a large patient population with a wide range of procedural training and obstetrics. Fewer come in with routine illnesses.

"This week we had 2 people in the hospital with ruptured diverticula requiring surgery and triple antibiotics, 2 elderly people in with pneumonia, and one patient with urosepsis. We took care of a pediatrician from our group with kidney stones, evaluated and sent someone to Madison with a complete placenta praevia at 28 weeks gestation who had bled (gave first dose of steroids here), ran a successful code blue on someone who collapsed in the next hospital room, and did a thoracentesis on another patient with a large pleural effusion. I don't think we have seen one snotty nose to blot all week." James Damos, MD, RTT Director

You will operate more as a partner with nurses, family physicians, specialists, and administrators. See also Why Choose a Small Rural Training Program

"I felt fully prepared when I finished my residency and now that I’m in my practice, I have found that I actually was prepared. In the residency, I felt like a partner, so the transition to having my own practice was easy." Eric Sorenson, MD, Menomonie RTT Graduate in 2000

You have the best of both worlds – a quality rural training experience with access to the resources of the core program. You will be able to take advantages of the rural lifestyle, be a part of the community, and still fulfill the requirements of residency training.

"I try to find out who my patients are. Getting to know what they do, the stories of their lives—that’s the fun part. In a bigger city, if a patient comes in with a stroke, she sees a neurologist…in a rural town you are the doc. You learn when to hit the panic button. You need to know when enough is enough and when you need somebody else to help you. You learn really quickly what you can and can’t handle. That in itself is quite an art." Bruce Schultz, MD, RTT graduate

The nation needs more well-trained rural family physicians. Twenty-nine percent (29%) of rural residents of the United States live in areas with a shortage of health professionals, compared to 9 percent of urban residents (Dalen, 1996). Family physicians provide 90% of the primary care in rural areas (AAFP). About half of family medicine programs have developed some kind of rural training. One of the most effective methods is Rural Training Tracks. These began in the late 1980’s in an effort to increase the number of physicians selecting rural careers.

Residents and even students preparing for rural practice must be able to make the decisions. They need to know what they can and cannot do. This cannot occur if specialists, faculty, or other residents make all of the decisions. Rural practice is challenging and you will be less likely to accept this challenge if you are not prepared. You are more likely to stay and be successful in rural practice if you prepare well. Objectives for Rural Programs and Curricula, Why a Preceptorship Is Better

Research indicates that the location of residency has an effect on the location of practice. We know that residents that spend more time in rural locations, in obstetrics, and in procedural training are more likely to choose a rural location upon graduation. More rural doctors graduate from programs with a rural mission and those where the program director has been a rural doctor. Research demonstrates that there is no advantage for community-based vs academic programs for going rural, you must examine the individual characteristics of the program (Bowman and Penrod, Family Practice Residencies and the Graduation of Rural Family Physicians, Family Medicine, 1998).

1. Programs entirely in rural areas for 3 years (about 30 programs)   See listing of Programs with over 50% rural graduation
2. Programs with rural curricula, clinics, and/or experiences integrated into the 3 years (another 20)
3. Rural Training Tracks with 18 – 24 months in a rural area (about 31 programs)

Rural Emphasis Family Practice Residency Listing at NRHA

The first method is entirely rural training. The second method is closer to traditional Family Medicine programs but with additional rural emphasis. The third is a newer model. The following is a description of the RTT method. Much of what is discussed applies to the other rural methods of training as well. The best way to find out about rural training programs is to visit, ask questions, call, and get the full picture. Often rural training programs will have excellent moonlighting opportunities. At the end of this handout you will find lists of rural programs, rural training tracks, and Family Medicine residency programs with excellent rural graduation rates.

A Rural Training Track (RTT) is an accredited, three-year residency training program that prepares physicians for rural family practice. Each RTT has 2-6 residents and is affiliated with a traditional family practice residency program.

RTT’s are "one-two" programs. RTT residents start training at the urban home program in traditional "block" format rotations like internal medicine, obstetrics, pediatrics, and surgery. In some RTTs the first year residents travel to the RTT site once or twice a week to begin building their outpatient practice. In the second and third years of residency, 90% of the inpatient and outpatient training is completed in the rural community. Often RTTs utilize the "longitudinal" format where residents spend short periods of time with visiting specialists over a much longer duration. Teleconferencing is used to connect rural sites with each other and with the traditional program to enhance didactic curricular requirements. Some residents live in the core program community for the first year and then relocate to the rural site for years two and three. Others locate in the rural site for all three years, commuting to the core program for the first year. There are usually monthly activities to gather all residents together for procedural workshops and other learning experiences.

Currently there are about 30 active RTT programs (Washington, Nebraska, Kentucky, Colorado, Illinois, Kansas, Montana, New Mexico, Michigan, Idaho, Louisiana, North Carolina, New York, Ohio, Oklahoma, and Wisconsin). The RTT programs originate in healthy medical communities with a solid core of family physicians and specialists. There is a wide variety of different types of practice environments in RTTs, but they are bound together by a common emphasis on teaching.

Recent research demonstrates that 88% of RTT graduates have chosen rural practice. There have been no problems with graduates passing their boards. Graduates report that they feel well prepared for rural practice. Studies continue in important areas such as how long RTT graduates stay in their original rural community. There is good indication hat more specific rural training will help rural physicians to stay longer in their rural practices. This is good for them and for their rural communities.

See a Family Doctor Affair - Thomas Rowley reviews status and recs for more rural docs

Telecommunications, informatics, practice networks, and many other innovations have long been a part of rural practice. Despite dramatic news articles, rural hospitals are on much more solid ground. Networking, community support, increases in reimbursements, and improved governance have stabilized and improved rural hospitals and health systems. Rural areas are changing. Cordes prepared a report in 1990 exploring myths about rural America. He stated that (1) rural populations in the US are no longer declining but increasing, (2) farming has given way to manufacturing as the major source of employment, (3) there are more similarities than differences in the economic structure of rural and urban America, (4) rural areas are no longer isolated from mainstream urban life, (5) rural people share much of the knowledge and many of the attitudes and beliefs of urban people, (6) rural and urban people are similarly happy with their environment, (7) rural America is much more diverse than previously thought.

Rosenthal identified five major elements of successful RTT’s: (1) academically sound urban component of program, (2) supportive urban medical center, (3) financially viable rural hospital, (4) modern rural practice unit, and (5) robust rural community. We think they will become increasingly popular with students interested in rural practice because they now have a track record and they are very relevant to one’s future practice. As far as career preparation they are equal to or better than traditional training. The nation does not need more specialization, but it does need physicians who can adapt to specific needs. The intensity and flexibility of rural training prepares residents well for future practice locations. Residents are finding their rural practice locations earlier and earlier and often use their final year to prepare specifically for their future practice location.

Are you required to enter a rural practice after graduation from an RTT? No, there is no obligation to do so. However, most graduates do choose rural practice.

What if I join an urban practice after graduating from an RTT? Am I at a disadvantage? No, you are not at a disadvantage. Residents receive more than adequate training in an RTT to practice anywhere, rural or urban or inner city or international. The procedural training, the front line experiences, and the heightened practice management may give graduates a significant advantage.

What kinds of students choose an RTT? Did they all grow up in rural areas? Many students come from rural areas, but there are also others who grew up in large metropolitan areas who realize the benefits of living in a rural setting. They are all committed to providing quality healthcare to the rural population. Our observation is that students attracted to RTT’s tend to be very independent, highly motivated people. They are not afraid to expose their weaknesses to grow as a physician and become the best possible doctor.

"I always knew I would be more comfortable in a small city. The residency only confirmed my belief that rural America is where I want to work and live." Bruce Schultz, MD, RTT graduate who grew up in suburbs in Colorado and Milwaukee

What if the rural residency program does not match? It is not a disaster or an indication that this is a weak program. Rural Training Tracks can operate well without a full complement of residents because they are functioning rural practices that are not totally dependent on residents to cover services. Because the instruction is individualized, RTT’s seek well-qualified applicants who will fit well with the practice. They are willing to leave positions unfilled until there are quality candidates. Rural programs are the new kids on the block. They are out of the main stream and have difficulty getting the word out. Their major problem is the fact that medical schools do not admit the right students that are interested in rural practice.

Do rural physicians and rural residents work harder than their urban counterparts? Yes and No. The number of patients, the variety and volume of procedures, and the degree of involvement with patients is probably more in most rural settings than in urban settings. However, the rural physician’s time may be more flexible with less stress. Close teamwork makes a difference in the work environment. Rural professionals and non-professionals mix together freely to address specific needs. Family physicians, specialists, home nurses, office staff, family and community can work together in patient-specific, non-traditional ways.

What is the major challenge of rural practice? Regardless of practice locations, the major challenge of both rural and urban graduates is being able to balance personal and professional aspects of a medical career. Those who learn to delegate, say no, (or later which is a form of "no"), and manage time will do well. Those that don’t learn these lessons will move from location to location, wasting much in terms of emotional energy and also in health system resources. Those in rural practice tend to face more challenges in the early years, but with increasing years in practice they have more sources to draw upon to keep practice aspects in balance.

Do you feel uncomfortable meeting your patients in the grocery store or on the street? Not at all. In rural areas, your patients are often your neighbors and friends. They tend to respect your role as a physician, but are able to separate the private and professional life. Rural sociologists describe a "connected independence" that aptly characterizes this unique arrangement. In many instances patients will benefit from the fact that you see them or hear about them in more than just an office setting.

Can spouses of residents and rural physicians find work in a rural area? There are a wide variety of rural towns with rural training tracks. This is also true in rural practice locations. If the spouse has a professional or highly specialized career, the couple may want to choose a location that is in a college town or is closer to urban areas. Some spouses are enthused about taking some time to enjoy the rural lifestyle with their family.

Do residents in RTTs interact with special populations in the area? Those who choose rural training and practice want to serve. RTTs work with reservations, disadvantaged populations, community and migrant centers, and other agencies that care for special populations. RTTs take care of everyone, just like rural physicians in actual practice.

How do you know that an RTT is good? Are there enough family practice faculty? Are other specialists available for teaching? Are current residents happy and are the graduates satisfied with their training? Are there extra opportunities to stand on your own? Many residents report hundreds of additional hours of experience while moonlighting in a variety of rural locations.

Do you ever get caught without a safety net when providing patient care in an RTT? RTTs have the same guidelines and safeguards as urban programs. There are systems to guarantee that you will have backup. The systems in rural programs are less complex and less likely to break down. Residents often share call with established physicians. This does not mean that mistakes will not be made. Residents in rural training have the opportunity to actually do too much. It is important to learn your limitations to be an effective rural physician.

How good is the teleconferencing? Most locations have some type of system that allows them the RTT residents to participate. The cost has continued to drop and the quality has improved greatly.

How do RTT’s differ from RTT’s in other states? You would have to judge that for yourself. Some RTTs are in smaller locations. Sometimes they serve different types of populations. Some have more of a private practice feel. Others have more variety of specialists. Some have more rotations in nearby areas. Rural practice is typically provided in groups where family physicians provide the majority of the care in collaboration with smaller numbers of specialists. Over two-thirds of the rural family physicians provide maternity care. Rural areas are often part of larger practice networks that give them access to a wide variety of specialists and specialist services.

Do rural physicians make less money than their urban counterparts? No. Many rural physicians make substantially more. Most would agree though, the reason for rural practice and training is not the money. It is about making a difference in lives. If money is your interest, please subspecialize and keep rural training pure. Family physicians in states with significant rural populations tend to make more money on average. They do work a few more hours a week on average. This gap has narrowed in recent years. Residents graduating from RTT’s in 2001 report that starting salaries cited were $20K more for rural positions. Graduate surveys validate this finding.

How can I familiarize myself with RTT’s while I’m in medical school? An elective is a good way to check it out. All RTTs would be happy to have you visit or stay a few weeks. You can also do research via the internet. Visit the sites during medical school and talk with faculty and residents. RTT residents are the best sources of information. Some schools are starting Rural Family Medicine Interest Groups and it is not uncommon to find rural programs at regional STFM meetings or residency fairs. The AAFP Student-Resident Meeting in Kansas City in July always has a good rural showing. The current Rural Training Tracks are listed later in this handout.

Further information for students interested in rural practice can be found at: http://www.unmc.edu/Community/ruralmeded/student.htm

You can check the AAFP Directory of Family Practice Residency Programs at http://www.aafp.org/residencies/.

A listing of programs with rural orientation is noted at this AAFP web site

For listings of rural training tracks on the internet: http://www.unmc.edu/Community/ruralmeded/model/gradu/RTTweb.htm

The Rural Medical Educators would like to thank the Wisconsin RTT Programs and Carrol Christman for the bulk of the preparation of this guide. "Nationalized" editing by Robert C. Bowman, M.D.

Rural Training Tracks in Wisconsin:

Antigo Rural Track – Wausau Family Practice Residency Program

Hilary Scully, MD, Program Director Mary Zaglifa, Recruitment Coordinator

(715) 675-3391 [email protected]

Baraboo Rural Track – Madison Family Practice Residency Program

James Damos, MD, Program Director Linda Scheid, Recruitment Coordinator

Phone (608) 263-4668 [email protected]

Menomonie Rural Track – Eau Claire Family Practice Residency Program

David Eitrheim, MD, Site Director Sue Jackson, Recruitment Coordinator

(715) 839-5177 [email protected]

Mauston, Wisconsin – Mile Bluff Clinic

Nancy Ness, M.D., Site Coordinator

Phone: (608) 847-9707 Email: [email protected]

Prairie du Chien, Wisconsin – Gundersen-Farrell Clinic

Mark Grunwald, M.D., Site Coordinator

Phone: (608) 326-6466 E-mail: [email protected]

Try out these other RTT Sites Across the Nation

More about Rural Training Tracks at Rural Training Tracks

Underserved - Overview and Models

www.ruralmedicaleducation.org