STRUCTURE AND TEXT ADAPTED FROM THE AFMO Research Subcommittee Report as of January 2, 2001

The intent of this project is to work with NRHA, AAFP, AFMO, etc to meet on a regular basis to work across divisions to facilitate rural medical education. NRHA may have significant editing needs but this may be close to AFMO standards.

Vision for Rural Medical Education: Family physicians are the heart and soul of rural health care delivery. Rural communities depend on Family Medicine to provide more rural physicians, better ones, and ones that stay longer in practice. Rural medical education efforts enable rural peoples to have more access to care and better care. It reduces the dependence of underserved communities on the rest of the nation. To achieve this goal will require an increased number of trained and experienced rural medical education faculty, coordinators, and preceptors to lead, guide and facilitate this process.

Background: Development of rural medical education capacity in family medicine should be a high priority. The American Academy of Family Physicians has yet to launch a major rural medical education enhancement initiative. This is puzzling because students, faculty, and programs connected with rural medical education have contributed much to family medicine. Nearly half of family physicians are rural physicians, have been rural physicians, or have had some part in the training of physicians for rural practice. Nearly every AAFP president and doctor of the year has been in rural practice. Former rural practitioners lead many departments, associations, and even the AAFP itself. Over 800 of 2500 family medicine M.D. or D.O. faculty have been in rural practice.

The promise of physicians for rural communities has been a primary reason that Family Medicine continues to receive federal and state funds. For decades leadership in rural medical education has been dominated by family physicians. Family Medicine has passed on several opportunities to house a major rural medical education effort, but it has failed to respond on several occasions. This includes requests from the STFM Group on Rural Health and the fledgling National Association of Rural Medical Educators. This group is now working with the National Rural Health Association, but hopes to combine efforts with the families of Family Medicine. Efforts of this group to improve admissions in medical schools to get service-oriented students admitted would directly benefit family medicine organizations, residencies, and practices across the nation. Another opportunity is in the wings. This May the rural medical educators will be meeting to decide the course of rural medical education for the next decade or longer. Hopefully Family Medicine will respond.

A. Linkage:

Because family medicine rural medical educators are widely distributed, often without a critical mass at a single center, building capacity across the discipline will involve building linkages. Examples include linkages between novice and experts, linkages between those interested in a common topic, linkages across academic and research community networks, linkages with rural medical educators from other medical and non-medical disciplines, and linkages between osteopathic, allopathic, predoctoral, research, and practice communities. The Internet and national meetings have been primary vehicles to facilitate these linkages. The usual Family Medicine vehicles have not assisted linkages in rural medical education. Rural faculty development at the national level has been provided by only one federally funded program lasting from 1990 to 1992. Conference activities have never centered on rural medical education and most family medicine conferences have few, if any rural topics. Often the effort has been a token rural presentation, attended by a broad variety of those needing help. For example, a single rural health topic is a common AAFP Annual staple. Yet at this meeting there are those interested in practice management issues, those facing difficult adjustments to rural practice, and those involved in teaching. Instead of two or three different talks to address the needs of a variety of rural folks, one rural talk is repeated 4 times.

Without adequate rural medical education infrastructure, it is impossible to build rural medical education capacity. Building this infrastructure begins with ensuring that family medicine leaders, such as academic department chairs and program directors, have a better understanding of the rural medical education process, and of the types of infrastructure services and skills required to support a successful independent investigator. Infrastructure needs include: rural medical education centers with a critical mass of experienced investigators willing to support each other and to mentor others, adequate amounts of protected time for academic faculty and practicing physicians to pursue rural medical education, academic tenure track rural medical education positions (and the equivalent positions in large medical groups), positions and support for non-clinical faculty so important to family medicine rural medical education, as well as grant administration and management support. This infrastructure and the experienced, successfully funded senior rural medical educators will serve as role models, mentors, collaborators and potential funding sources for less senior educators, faculty and students, ultimately increasing the cadre of rural family medicine educators and researchers.

To effectively build rural medical education capacity, it will be necessary to enhance the training of rural medical educators at all levels. This will include pipelines for students into rural medical education careers, identifying and supporting mentors for novices, encouraging and supporting visits to rural sites and practitioners and other rural medical education programs, and developing and presenting workshops for basic and advanced rural medical education skills, supporting and expanding rural medical education-oriented family medicine fellowships and encouraging family medicine participation in multidisciplinary rural medical education fellowships. The goal is to build a critical mass of skilled, energetic, independent investigators in the discipline. However, a period of formal training or fellowship is seldom sufficient. An additional 2-3 year period of mentored and financially-supported work is usually necessary to move from trainee to fellow to funded researcher or educator. Most people will require at least 50 to 80% protected time during this period to become independently funded. Rural family medicine researchers and educators should also be encouraged to take advantage of career development awards from the National Institutes of Health, Robert Wood Johnson and other agencies that provide 3 to 5 years of support to advance junior rural medical educators to independent and senior levels. Renewal and expansion of rural faculty development programs, partnering with existing family medicine efforts, would do much to insure a better rural medical educator in future years.

Some capacity in rural medical education will naturally need to flow from rural practitioners. This will mean that students and residents and faculty will need to travel to rural locations. Also funds will be needed to support educators even though the department or program will not have total control over the time and decisions of this person. This creates some unique dilemmas. Some of the best research and education ideas and work ethic flows from rural practitioners, yet these are individuals with very little time to devote to these efforts. Rural physicians or former rural physicians are in demand for clinical skills, procedural skills, and practice management expertise.

The ultimate measure of rural medical education capacity in family medicine is the extent to which practicing family physicians feel supported by and pride in the rural medical education output of their discipline. To have more and better rural family physicians who stay longer in rural practice will serve departments, programs, and family medicine well. A secondary measure of rural medical education capacity is the extent to which family medicine educators are recognized for their work by those in other disciplines and by funding agencies. This can include receiving grant funding, serving on key national or state advisory committees, participating in consultations, and receiving invitations to present results.

Educators will not only need to develop national models, they will need to see these models successfully adapted and replicated to a variety of different areas of the nation. More broadly, success in rural medical education will be measured by the extent to which the agenda influences the national agenda. Specific goals should include having rural medical educators on National Advisory Boards, at multiple positions in federal government, and in key locations in national organizations and funding foundations. Rural medical educators will need to facilitate the exchange of information between local, state, and federal levels and across the nation and beyond the boundaries of primary care, allopathic, or osteopathic division lines.

An important aspect of building rural medical education capacity involves publication and dissemination of rural medical education results. This requires adequate space for family medicine original rural medical education contributions in rural and family medicine journals supported by the entire academic community. Overall, the number of rural family medicine manuscripts submitted and accepted for publication must increase. The results of original works should also be presented and disseminated in other creative ways to increase the impact on the nation in service, education, and research arenas. Given the dispersion of educators, electronic means are appealing and electronic journals are beginning operation in rural health and rural medical education.

Building rural medical education capacity will inevitably involve enhancing the culture of family medicine. This begins with creating an environment within the specialty in which service to the underserved is a valued, expected, and enjoyable activity. The expectation should be for all family physicians and all family medicine faculty members to be involved in some way in service to the underserved. Family medicine organizations and academic family medicine departments can facilitate this culture change by explicitly valuing rural educators and programs, by instilling an appreciation and understanding of rural medical education among students and residents, by developing centers of rural medical education excellence, and by supporting the development of independent investigators who will develop a coherent line of rural medical education activities and programs. Family medicine should build upon its unique integrative role in health care to advance rural medical education efforts to include multi-disciplinary and multi-method approaches.

Other areas of emphasis with a direct application to rural medical education include service-learning efforts, international efforts (missions and replicating family medicine), and supporting various student interest groups and voluntary efforts. Research demonstrates that students and faculty interested in rural health careers participate in these efforts.

A rural medical education agenda that will change practice and the delivery of health care, and that will foster increased demand for rural medical educators must begin by asking the right questions, questions that lead to knowledge that helps to enhance the health or health care of patients in rural areas. A good question should address common practice or policy problems, integrate a practice-based/relationship-centered perspective, and respond to the needs of clinicians, policy makers and funding agencies’ agendas. These questions should be answered in the appropriate rural primary care settings. One goal of asking and answering the right questions will be to create physicians who understand rural medical education. This is facilitated in experienced programs where students do long term preceptorships, return to these locations or similar ones after graduation from residency, and train new generations of students based on what they were taught as students at rural locations and learned throughout training in family medicine rural programs.

Sustaining and increasing family medicine rural medical education capacity requires growth in funding granted to educators and researchers. Sources of such funds should state governments, medical schools, federal sources, the Federal Office of Rural Health Policy, the Division of Primary Care, and various foundations grants will be necessary. Increasing funding awards will require increased numbers of grant submissions, both investigator-initiated grants as well as those submitted in response to specific Request for Proposals. Alternative sources for sustainable investigator-initiated grants, such as the pharmaceutical industry (with appropriate guidelines for publication) must be explored.

Addendum: Specific items identified by committee members:

A. Linkages:

1. Across all medical and non-medical disciplines
2. Between investigators and educators and practitioners
3. Between novice educators and experts (i.e. internet work links)
4. Among rural medical educators with similar ongoing projects or common interests
5. Among groups of active rural medical educators
6. Between rural medical educators and support systems
7. To facilitate thinkers, planners, administrators, and leaders

B. Infrastructure:

1. Develop and fund rural medical education centers of excellence
2. Develop a critical mass of rural medical education expertise in key departments
3. Protect faculty time for participation in rural medical education
4. Create and fund positions for coordinators and non-clinicians and retain them in service
5. Educate chairs and family medicine leaders regarding the rural medical education process
6. Define and teach rural medical education administration skills
7. Create tenure track rural medical education positions
8. Clarify and develop family medicine rural medical education career paths
9. Assist more advanced rural medical educators with funding application process
10. Increase the number of rural medical educators capable of leading well funded, major rural medical education projects.
11. Identify sources of funding for time for RME project development/grant writing
12. Develop and fund rural medical education support services
13. Develop rural medical education homes
14. Increase the number of rural medical education mentors, non-academic based rural medical educators and role models

1. Develop mentors for rural medical educators at all career stages

2. Facilitate pipeline to guide students into rural practice and rural medical education careers

3. Produce strong, independent investigators

4. Develop educational programs for trainees at different levels

5. Expand the training opportunities for rural medical educators at all levels

6. Facilitate the ability of senior rural medical educators to mentor new less-experienced rural medical educators

7. Develop the expertise among family medicine rural medical educators to educate their other colleagues in the discipline

8. Increase family medicine rural medical educators’ technical knowledge

9. Develop and facilitate attendance for advanced rural medical education

10. Provide settings and programs to all young investigators sufficient time and experience to develop rural medical education skills – 50% x 2 years.

11. Develop basic rural medical education skills workshops

12. Develop advanced educational opportunities, partnering with existing family medicine faculty development efforts and governmental agencies

13. Develop 5 to 10, 1 to 2 year rural medical education fellowships that include 80% rural medical education, include internet-based training to increase participation

1. Develop a family medicine rural medical education agenda
2. Change the existing national rural medical education agenda
3. Enhance rural medical educators’ national / international reputation
4. Highlight areas of rural medical education focus for the needed for the field
5. Define rural family medicine as relationship-based medicine
6. Place rural medical educators in AMA / AAMC advisory positions
7. Ensure that family medicine rural medical educator accomplishments are recognized
8. Increase the local, regional, national and international influence of family medicine rural medical education
9. Expand the biopsychosocial paradigms that are the basis of rural family medicine, particularly emphasize the mental health training and practice that is needed so much in rural areas.
10. Place 3 to 4 rural medical educators on national advisory boards and panels
11. Work with noted rural health and rural policy experts and those involved in rural education and rural sociology to integrate these areas into rural medical education.

1. Increase the level of scholarship in rural medical education
2. Enhance dissemination of rural medical education
3. Inform practice behavior
4. Increase peer-reviewed submissions’ and acceptances
5. Provide and highlight relevant rural medical education results
6. Increase the number of publications
7. Increase the number of vehicles for publication

1. Encourage rural medical educators who sustain a focused rural medical education trajectory beyond 1-2 studies
2. Change clinical / teaching / research environment to value rural medical education
3. Develop "identity" for family medicine department by creating centers of excellence
4. Break down walls between clinicians, teachers, researchers & rural medical educators
5. Change national medical education culture to place more value on rural medical education
6. Facilitate change within the discipline and within family medicine departments
7. Recognize and facilitate coping with the edge of chaos
8. Value scholarship within professional organizations
9. Develop a normative culture in which all levels of individuals from student to resident to faculty to practitioner to coordinator to rural community member participate in the development of new ideas, methods, and programs.
10. Facilitate intra- & inter-discipline infrastructure & culture
11. Encourage health services research related to rural medical education
12. Emphasize the ability of rural medical education to enhance the fun of family medicine
13. Use the practical example of rural practices and practitioners to kill marginal technology
14. Use rural medical education connections and efforts to eliminate unnecessary practice variation
15. Bridge the town / gown schism
16. Connect rural medical education with the evidence-based medicine culture

G. Asking the Right questions in the right setting:

1. Enhance and facilitate synergy among rural medical educators, clinicians and patients
2. Focus on facilitating better patient care
3. Do work that makes meaningful differences
4. Partner with patients, coordinators, researchers, educators, & other professionals
5. Investigate questions of importance to primary care and medical education
6. Encourage a diversity of methods, develop new methods and enhance "multi-method" studies
7. Develop departments' ability to respond to policy questions and RFPs from state governments and others.
8. Encourage a variety of projects, and programs
9. Encourage more evaluation of rural medical education projects and programs
10. Involve practitioners & investigators
11. Develop a "virtual" self-sustaining group of rural medical educator
12. Define priority questions
13. Forge practice based rural medical education networks
14. Create informed consumers of rural medical education.

1. Build effective alliances with rural business, foundations, and organizations
2. Encourage work with a variety of interested funding agencies
3. Identify and create sources of stable funding
4. Encourage rural medical education agendas with sustainable funding
5. Enhance the ability of rural medical educators and centers to be self-sustaining
6. Increase rural medical education funding
7. Increase rural family medicine RO1 submissions and awards
8. Increase the number of funded rural medical education programs
9. Enhance the ability of rural medical educators to compete successfully for external funding to support rural medical education