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    Training Physicians to Meet the Needs of Rural America


    Editor’s Note: Throughout 2015, an AAMCNews series explored how medical schools and teaching hospitals are addressing social determinants of health in their communities through research, clinical care, and education.

    Learning medicine “in the field” in rural North Dakota keeps third-year medical student Mark Rostad on his toes. Recounting a week that included a day in family medicine, two in surgery, and a fourth in obstetrics and gynecology, Rostad said the rapid-fire pace demands that he constantly refresh his medical knowledge. “That helps to reinforce a lot of the things I am learning. Out here in the rural setting, it’s just you and the doctors, and they will give you experiences that many medical students don’t get until they are residents.”

    Rostad is part of Rural Opportunities in Medical Education (ROME) at the University of North Dakota School of Medicine and Health Sciences (UND), a program that sends medical students to live and learn in rural communities. “The difference in these experiences is the hands-on learning that the students get one-on-one from teaching physicians,” said Kamille Sherman, MD, assistant professor of family and community medicine at UND and codirector of ROME.

    ROME and rural practicums at other medical schools are responding to a pressing need to address health disparities in rural communities and to encourage physicians to practice in these underserved areas. The Agency for Healthcare Research and Quality has found that rural populations are more likely to be “poorer, sicker, older, uninsured, and medically underserved than urban populations.” Obesity, diabetes, and certain cancers are more common in rural communities, as are male suicides. Alcohol abuse, smoking, and conditions related to poor diet are prevalent as well. In addition, access to health care can be compromised by transportation difficulties, a dearth of specialists, and the cost of medical services.

    “In the rural setting, it’s just you and the doctors, and they will give you experiences that many medical students don’t get until they are residents.”

    Mark Rostad, medical student University of North Dakota School of Medicine and Health Science

    Rural immersion programs may differ depending on the characteristics of the community the medical school is serving. The Wisconsin Academy for Rural Medicine (WARM), part of an expansion at the University of Wisconsin School of Medicine and Public Health, admits 26 students each year. Students spend two years in medical school at the main campus in Madison and then relocate in their third and fourth years to complete clinical requirements in one of three regional sites that serve as gateways to rural communities.

    Each of the three sites developed its own approach to training students based on student and patient needs, according to Byron J. Crouse, MD, associate dean of rural and community health and director of WARM. The La Crosse site adopted a clinical longitudinal integrated curriculum—encompassing internal medicine, pediatrics, and family medicine rotations—that immerses students in the same community for 18 consecutive weeks. The Green Bay site uses block rotations but requires students to go to the same rural community for their primary care clerkship rotation early in the third year and then again in the fourth year. The Marshfield site also uses the block approach but with a greater number of clinical rotations in rural settings, such as one in pediatrics.

    To address the shortage of primary care physicians after Hurricane Katrina, Tulane University School of Medicine started the Tulane Rural Immersion Program in 2007 based on the WARM model. In the third year of medical school, students train in one of several rural communities. Their work includes projects they design, such as programs to educate patients about diabetes and obesity.

    Other programs are designed to develop future leaders in health care. The Columbia-Bassett Program combines study at Columbia University College of Physicians and Surgeons with clinical education at Bassett Medical Center in rural upstate New York. The longitudinal curriculum at Bassett offers a strong grounding in rural medicine and helps students explore career paths as they build patient panels and follow them.

    Students follow a curriculum called SLIM (Systems, Leadership, Integration, and Management), which includes training in Lean Six Sigma techniques. “We think that those skills and cultural approaches are essential to transforming health care,” said Henry Weil, MD, senior associate dean for education at Bassett.

    The Rural Physician Associate Program (RPAP) at the University of Minnesota Medical School places third-year medical students in nine-month rural immersions. “The panel of patients are the patients in the community,” said RPAP Director Kathleen D. Brooks, MD, MBA, MPA. The program is now 44 years old, with more than 1,400 graduates. “For me, wanting to do primary care, I don’t think I could have had a better experience,” said fourth-year medical student and RPAP alumnus Tyler Thorsen.

    Students at the Commonwealth Medical College learn about the community through the eyes of a single family that they follow beginning in their first year of medical school and until they graduate. “We find that is quite an important experience for the students to begin at the very start of their medical school experience,” said William F. Iobst, MD, vice dean and vice president for academic and clinical affairs.

    Perhaps the most important takeaway that medical students get from a rural immersion program is perspective. Said Iobst, “The goal is for students to understand from the care-receiving end what it’s like to be a participant in health care in this country.”

    This article originally appeared in print in the April 2015 issue of the AAMC Reporter.