AAMC Reporter: July 2008
Residencies Revolve Around Rural Care
While the old song says country roads may take you
home, they may not lead you to better health care.
Rural Americans face massive health care obstacles. Only
about 10 percent of physicians practice in the countryside,
although nearly one-fourth of the population lives
there, according to the National Rural Health Association
(NRHA). The NRHA also reports that 2,157 geographic
regions designated as health professional shortage areas
are in rural and frontier areas, compared with 910 in
urban settings. With this demonstrated need for more
rural providers in mind, new family medicine graduate
medical education (GME) programs have sprouted up
to turn out more doctors who are both willing and able
to perform countryside care.
Rural family medicine has a unique set of challenges.
Unlike physicians based in metropolitan areas, rural
doctors practice in remote places with few nearby specialists;
thus, these doctors need to provide a wide
range of services, from delivering babies to handling
traumas to treating older patients. When rural physicians
do collaborate with specialists, they may have to do so
remotely. They may also have to provide effective care
without all the latest diagnostic and therapeutic tools at
their fingertips.
The residency programs may be uniquely positioned to
reach the two-pronged goal of training doctors who
both want to practice in rural areas and are equipped to
meet the specific health needs of these regions. Because
they have a stated rural medicine focus, these programs
will most likely attract young physicians already interested
in this type of care. By offering extra support,
resources, and training, the programs can better prepare
residents for the challenges of rural medicine.
The West Virginia Family Medicine Rural Scholars
Program was developed in 2004. Perhaps its most innovative
component is that it starts early—trainees apply to the
program as third-year medical students. This selection
process helps identify those who are interested early in
their medical training. Students from West Virginia
University School of Medicine and West Virginia
School of Osteopathic Medicine may apply.
"A lot of women and men start medical school saying
that they want to practice family medicine in smaller
towns, but these numbers go down as people advance in
their training," said Konrad C. Nau, M.D., chair of West
Virginia University School of Medicine Department of
Family Medicine-Eastern Division. "We realized we
were missing a golden opportunity to get these people
engaged in rural care."
By offering direct community experiences via training
in small hospitals or small-group practices, the program
tries to instill skills necessary for rural family medicine.
Trainees gain exposure to the full scope of rural medicine.
Because it can be difficult for patients in rural areas
to get to the doctor, the program emphasizes interacting
with patients by phone, e-mail, or even through house
calls. At most training sites, an MRI machine is brought
in only once or twice a week; residents learn to decide
whether patients can wait a few days, or if they should
travel elsewhere for immediate MRI access.
Because residents often collaborate with specialists who are
not in-house, program administrators make resources
available for remotely consulting with these professionals.
A Medical Access and Referral System telephone line helps
connect residents to West Virginia University faculty.
"We can dial in and say, 'I need to talk to somebody in
pediatrics infectious diseases,'" said Justin Glassford,
M.D., a rising second-year resident. "Often we are looking
for guidelines or treatment alternatives, and talking
to a specialist can open these avenues."
Good decision-making skills are necessary when communicating
with specialists remotely.
"Ultimately, you have to decide whether to follow these
specialists' recommendations," Glassford said. "They are
still your patients, you are the one examining them, and
you are in charge of their care."
Accepted students receive a $10,000 scholarship. There
is no obligation for program graduates to practice in
rural America, but Nau said that the program's first three
alumni have pledged to stay in small West Virginia towns.
"If we are selecting the right people and rewarding
them with a stipend and a quality training experience,
that is going to work out on its own," Nau said.
The Hanford Family Practice Residency Program in
California's Central Valley opened its doors to residents
in 2006. Hanford is the rural track of the Loma Linda
University Medical Center (LLUMC) Family Medicine
Residency Program, headquartered about 60 miles east
of Los Angeles.
After spending their first year at Loma Linda, residents
move to Hanford's rural environment, where they train in
a longitudinal model. This means that residents alternate
between half-day blocks of learning specific aspects of
family medicine. In a single day, residents may work in
an intensive care unit, treat diabetic patients, and assist
on a chest surgery, said Program Director Daniel L.
Engeberg, M.D.
By continually switching gears, residents become better
accustomed to the many medical roles they are expected
to play as rural care providers.
"A rural family physician must immediately be ready to
do something different," said Jamie Osborn, M.D., program
director of the LLUMC Family Medicine Residency
Program. "If we can train residents for something different
every few hours, we can simulate real-world rural
family medicine."
Residents learn to rely on their clinical judgment
so they can be effective practitioners in areas with
limited resources.
"Outside the patient's room, we constantly ask residents,
'If you didn't have this test available, what would you
do?'" Engeberg said. "Residents are surprised about how
accurate they are."
Like West Virginia, Hanford's program is contributing
to improved rural health access: Its first two graduates
will stay in rural California to practice family medicine
doctors.
—By Elissa Fuchs
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