More Medical Schools Boost Primary Care Doctors Through Small-Town Campuses
AAMC Reporter: July 2012
— By Gina Shaw, special to the Reporter
Having grown up on a farm in Michigan, David Chapel knew from the moment he decided to go to medical school that he wanted a career in rural medicine. By his senior year at the University of Michigan, he was leaning toward staying there for medical school—until he learned about a new track in rural medicine at Columbia University College of Physicians and Surgeons in New York.
The Columbia-Bassett program, a partnership with the Bassett Healthcare System in the upstate New York village of Cooperstown—best known for the Baseball Hall of Fame—accepted its first cadre of Columbia students last fall.
For the first 18 months of medical school, “Bassett track” students attend core “foundations of medicine” classes at Columbia’s northern Manhattan campus. Then they move to Cooperstown, where they plunge into a longitudinal clinical experience that allows them to assemble their own patient panels and follow those groups throughout their medical care.
“It isn’t specifically a rural medicine program, but the fact that the Bassett track gives you a longitudinal major clinical year in a rural environment is a real plus,” said Chapel, who will be moving to Cooperstown in January.
Columbia-Bassett is one of the newest rural or small-town regional campuses at a major medical school. These are more than limited clinical rotations at distant sites; they are fully functional branches of the main school where small groups of students receive their entire four years of undergraduate medical education, or at least the lion’s share of their clinical experience.
At a time when the AAMC projects a shortage of 90,000 physicians by 2020, the leadership at a number of medical schools hopes these programs will recruit students with an interest in primary care, who will put down roots where they train and practice there after they complete residency.
Perhaps the newest and smallest of these programs is the University of Kansas School of Medicine’s campus in the north-central Kansas town of Salina. The first cohort of eight students started classes in the fall of 2011.
During a Liaison Committee on Medical Education (LCME) visit to the campus several months ago, a fourth-year Kansas student doing a clinical rotation in Salina summed up the appeal of such campuses to Robert Sabalis, Ph.D., the AAMC’s director of LCME surveys and team training. “She said to me, ‘I’m from a town of 400 people, and I was overwhelmed by the large class size and big city when I first came here,’” Sabalis recalled. The student advised Sabalis that if medical schools want to recruit good students from towns like hers, who might then go back and practice in those areas, they should strive to educate those students in a similar environment rather than making them move to the “big city.”
Varying structures, similar goals
The challenge is establishing a true full-service medical campus in an isolated rural area. Salina has a population of 50,000, large compared with Cooperstown village, which is only about 2,000. Bassett Healthcare, however, serves an eight-county region and recently ranked among the top 50 integrated health care systems nationwide.
“You need some concentration of medical resources to have a medical school, and that’s difficult in a town of 200,” said Steven Stites, M.D., interim dean at Kansas and chair of internal medicine. “But for our students who come from a town of 200, a town with a population of 50,000 is a lot more comfortable than one of 2 million. The medical school is new, but our residency training program there has a long reputation for providing care to people from rural areas and has already put doctors all over the western and northern half of Kansas. We believe the medical school campus will build on that.”
Salina was chosen carefully, Stites added. In addition to enthusiastic community support, the town offers a different physician mix at its hospital and clinic sites from that found in Kansas City. “Here at the medical center, we have about 90-plus percent specialists and 10 percent or less primary care physicians. In Salina, the mix is about 50-50 between primary care and specialty.”
Texas Tech Health Sciences University has two four-year medical schools: a new school located in El Paso, which opened in 2009, and the original school, located in Lubbock. With the opening of the El Paso program, the Lubbock school added a program at its Permian Basin campus, midway between the oil-boom towns of Odessa and Midland.
“The Permian Basin campus provides clinical experiences for third- and fourth-year medical students in all six core specialties, including family medicine, internal medicine, obstetrics and gynecology, pediatrics, psychiatry, and surgery,” said Regional Dean John C. Jennings, M.D.As with Salina, the Permian Basin region isn’t entirely rural. The campus serves a population comparable in size to that of the main campus in Lubbock and the other regional campus in Amarillo, but it is spread over a wider geographic area. “We service a 17-county region almost as large in area as the Northeast United States,” Jennings said.
Almost universally, students and administrators say that future physicians choose these programs because of the personalized education they receive, as well as the more intimate community setting. “When our first students came here in 2009, they were welcomed with a reception from the Chamber of Commerce,” Jennings said. “We have 18 students in the Permian Basin program and 140 clinical faculty this year. So our students can be guaranteed to know their faculty very well.”
The situation in Salina is similar, said Heidi Chumley, M.D., senior associate dean for medical education at Kansas. “There are plenty of M.D.’s in Salina ready and willing to help, and because the numbers of students are low, they have more contact and more involvement. For example, when the Salina students are learning cardiac anatomy, it’s easy to take eight students to the cath lab and let them watch. It’s a little harder to give a group of 175 students that same experience here in Kansas City.”
Where there are gaps in resources, technology takes over. The classrooms at the Salina campus are equipped with video monitors, webcams, and microphones, enabling students to participate in live lectures from the main campus in Kansas City.
Rural areas and relatively small towns are excited to have medical school campuses in their midst, said Maryellen E. Gusic, M.D., executive associate dean for educational affairs at the Indiana University School of Medicine, the state’s only medical school. Indiana has eight M.D.-granting branch campuses in addition to its main campus in Indianapolis. “Near one of our campuses, the enthusiasm and opportunity for the community is represented in the billboards advertising ‘homegrown physicians.’”
Indiana’s regional campuses were created to educate students during their first two years of medical school, after which they would move to Indianapolis for their clinical training.
“We began expanding our matriculating class in 2007 in response to national data as well as a state study about the need for more physicians in Indiana,” Gusic said. Soon after that, the school piloted clinical rotations at campuses outside Indianapolis. “We’ve now fully incorporated the opportunity to do all third- and fourth-year clinical rotations at four of our campuses and will add two more this summer.”
None of these campuses is in true “rural” areas, or even very small towns, but with the exception of the 200,000-plus Fort Wayne, they’re all in towns with fewer than 100,000 residents. Terre Haute graduated the first cohort of students in its Rural Medical Education Program in May. These students spent all four years at that campus and did their clinical rotations in various sites, including rural practices and critical access hospitals. Seven of the eight students graduating this year are entering primary care.
Because many of these programs are new, administrators have sought incentives to attract students. Columbia-Bassett students receive $30,000 per year in scholarship support from a private grant. Permian Basin students get between $10,000 and $15,000 annually. At Indiana, scholarships are available for students in the Rural Medical Education Program, as well as for those pursuing primary care. The community in Salina also is pouring money into scholarships for medical students, Chumley said.
There are challenges for these small-town and rural campuses, but small class size doesn’t appear to be one of them. “Because there’s not the volume of students here, the experiences I’ve had have been extraordinary,” said Katherine Schwartz, a fourth-year student in the Columbia-Bassett program and part of the first group to go to Cooperstown. “In my surgical rotation, I had worked with the same surgeon and resident team for three inguinal hernia repairs in a row. The first time, the attending was quizzing us. And then for the second two, the attending just stood back and let the resident do the surgery. That was a phenomenal, powerful educational experience.”
In Kansas, Stites sees these campuses as providing a model of distributed education. “We’re taking advantage of modern technology to meet health care needs in an underserved area.”
The days when everything in medical education is centralized at one main campus may well be a thing of the past.