INITIATE RURAL PROGRAMS EARLY When considering the timing of rural programs, it is important to remember "to vote early and vote often". Students form their concept of what a doctor is at an early age. Some have role models in families or close friends. Those in rural areas (with fewer health providers) have less opportunity for these exposures as their potential role models are too busy or less available. School counselors in rural areas have little time to deal with problem students, much less gifted ones. Programs to encourage rural health careers should start in high school or before. Medical students and incoming FP residents examine faculty, and other residents and students in their environment and compare that with what they would like to become. Initial impressions can impact on the decision for rural practice. The evidence suggests that later timing is bad for career decisions regarding family medicine
CONSIDER LEARNER-CENTERED PROGRAMS Medical education seems to work mainly due to the quality of the applicants rather than the effectiveness of the teaching. The lectures, the exams, and the rigidity of the curriculum do not facilitate individual learning. One of the strengths of rural programs may not be so much the rurality as the intimacy and learner-orientation. Academics may present facts and discuss some biomedical areas, but they also impart a distancing effect where people become diseases or numbers. This impairs preparation for primary care and rural careers where intimacy is an expectation.
OFFER MORE THAN MEDICINE Since rural preceptors are often the only "peer" contact for the students, the learning can go far beyond clinical skills. Appropriate program design can faciltate this type of learning. ETSU's Appalachian Preceptorship prepares students with an introductory week emphasizing the doctor-patient and physician-community relationships. This prepares them to examine these relationships as they spend a month with a top-notch rural physician. Nebraska's required Core Rural Rotations help residents develop a relationship with a practice and a community over a two month period far away from the urban training sites. Residents often leave as trainees and come back physicians.
MEDICAL STUDENTS NEED ASSISTANCE WITH CAREER CHOICES Students considering a career in rural health need primary care training. They should be advised by primary care physicians, preferably those with rural practice experience. They should choose those residency programs that emphasize hands-on patient care, training in procedures, and rural health experiences. The match is a critical step in the preparation for rural practice. Students can receive information about such residencies by handouts, newsletters, discussions, or advisory conferences. The STFM will soon produce a Rural Programs Compendium. The best attended presentation at the AAFP National Conference of Students and Residents is the session on Preparing for Rural Practice. For many students, this is the only rural career orientation that they will receive.
EMPHASIZE A "HANDS-ON" APPROACH Students who plan rural health careers are advised that they need the full seven years of medical education to obtain the clinical, procedural, and practice management competence that they need to be comfortable with rural practice. Students preparing for rural practice should be encouraged to "take charge" of their patients. A "hands-on" approach may be more risky to faculty and institutions, but it is necessary for rural interested students. Clinical experiences in the third and fourth years confirm their interest. These students are encouraged to choose residency programs that will facilitate these rural goals. Faculty must also make a commitment to "hands on" by learning and teaching procedures, going out to sites, visiting with rural physicians and community leaders, and advising trainees.
USE RURAL LOCATIONS This seems fairly obvious, but it is often overlooked. Interactions with rural role models and some understanding of the rural way of life are impossible to accomplish without rural communities. In a sense the entire community becomes the training location. Eighty of 126 medical schools have rural preceptorship experiences. Even students without these programs can access national programs such as HPDP, COSTEP, and the Appalachian Preceptorship. Each year these programs turn away hundreds of medical students. Students can arrange their own rural preceptorship through contacts with physicians, rural organizations, state academies of family practice, or family practice departments..
THE LENGTH OF TRAINING MAY BE IMPORTANT Exposure is important, but one or two months may not be long enough. RPAP students in Minnesota are overwhelmed by rural primary care at 3 months, neutral to it at 6 months, and do not want to leave it at 9 months. Some urban sites have nearby rural teaching sites within reasonable access for longitudinal training. This allows residents to experience continuity of care and other strengths of rural practice. Some residencies in smaller towns can easily develop an ambulatory site that is rural, but keep the RRC required hospital, subspecialty base. Many residencies are actively developing rural training tracks of up to two years in length. To date six sites are accredited and more are at the stage of the site visit.
ORIENTATION A PRIORITY Those who will enter rural communities benefit from some initial preparation. Appalachian Preceptor students receive a week of instruction on rural institutions, providers, and the effect of culture on health care. They examine the role of the physician in the rural community. Students armed with this information are seeking out the rural difference from the start instead of emphasizing only the clinical and biomedical aspects. Students should be aware of their responsibilities and the clinical opportunities. Some if not all students should be aware of local customs regarding dress and behavior.
INTERACTIONS ARE CRITICAL Medical education pits students against a mound of educational material. Successful health care involves mastering people skills. Medical education typically retards the natural maturation process of learning to deal with others on an adult level. Somehow educators must reconcile these very different goals. Some programs emphasize the doctor-patient relationship. This is useful for all medical students, but rural physicians must often go beyond the person and family to that of the community level. To educate in this area is is useful to form teams of students from different disciplines. Physicians who choose rural communities must "grow up" fast. They must learn to balance their own needs with those of their practice and the community. They need to learn to cooperate and delegate. Interpersonal skills are critical to rural physicians. These needed assets can be learned from role models or they can be developed in small group situations wrestling with programs or projects with others from different backgrounds. AMSA's Health Promotion and Disease Prevention project excels in this area. Students work with community members on a health project.
BE WARY OF SIZE, PROXIMITY, AND POLITICAL NEEDS Rural program directors often have a choice of establishing larger rural academic centers, picking a few nearby sites, or diffusing trainees over wide and smaller locations. It is certainly easy to initiate, staff, accredit, and control large centers, but academic centers (even the more rural ones) have no track record of producing rural physicians. They can easily resemble the urban tertiary academic centers that defeat the purpose of the rural experience. These centers can also alienate the local providers and community if the development is not mutually beneficial.
CHOOSE LOCATIONS AND FACULTY WISELY There are many reasons to establish rural programs. Local and state political entities may be desperate for medical services. Educators want good training faculty. Administrators want support for facilities and faculty with established community contacts. Some communities reach out and support programs and some do not (due to history, economic decline, lack of leadership, or other reasons). A quality rural training location must have good faculty, community support, and political support. If faculty are to be hired, they must be compatible with each other and the community. This is often not an easy matter and it may be easier to select locations with compatible physicians who want to teach. Rural educational programs designed to "fix" health problems can often cause more health problems and convince graduates that rural practice is not for them. The quality of other health providers must also be considered as trainees will contact them during their stay. Often the location is a matter of proximity to the main program with few or no providers who can serve as faculty. If faculty are new to the area, it is important to expect a slow development of programs in such locations as it takes time to develop contacts, community educational resources, and a patient base. In these situations it is important to have long term support and a generous number of physicians. Promises must be made cautiously if at all in the first years.
ADDRESS RURAL FACULTY DEVELOPMENT Both academic and practicing rural faculty need faculty development. It is tough to move to an academic setting from a small individually controlled rural practice. Rural practitioners who move to the academic setting need to understand the medical school environment, the forces that shape primary care on a federal, state, and local level, as well as develop academic and leadership skills. Perhaps the most difficult area for physicians turned faculty is to deal with the particular problems of their previous rural practice setting. Each practice and community has bad and good areas just as each practitioner had strong and weak areas. Rural faculty need updated information about rural programs, they need contact with other rural faculty, and they need to work with state government and organizations. Practicing physicians often need special training in adult learning theory, teaching techniques, student evaluation, and advisement. Some rural physicians are concerned that they might lack skills or expertise. They need to realize the strengths of their rural practice - their own problem solving skills, the network of consultants, and the information resources at their disposal. They also need to know how to develop the local curricula for a better overall rural experience.
EVALUATE AND RESEARCH THE EFFORTS Rural academics must balance the rigorous standards of academia with the practical considerations of running rural programs. Research is greatly needed in the decision for rural practice so that programs can be revised and designed. The example of RPAP is notable in this area. RPAP evaluations are not only the most detailed rural program evaluations, they are probably the most detailed evaluation of any medical school clerkship. It is important to anticipate the information that will be needed to support rural program so that you can design questions to provide these answers. Evaluation begins with program design, not after the first few years. There is a great need for prospective studies involving rural programs. Most of the studies are repeats of what is already known. Qualitative methods may help to break new ground in this area.
OVERALL COORDINATION OF RURAL PROGRAMS REQUIRES MUCH EFFORT. Grants of various types aid in this effort. Area Health Education Center grants support management and coordinating personnel, networking with community providers, and training efforts. A local program director or coordinator is often overlooked or cut. This person is perhaps the most important in developing the community experiences and social life of the recruit. Calendar arrangements, housing, friends, and church visits are just as important as precepting or hospital experiences.
ADEQUATELY FUND THE RURAL PROGRAM Multiple sources are available for funding rural programs. Hospitals often utilize rural programs to get or keep physicians or patients. They may support programs just for the possibility of recruiting one of the trainees in the future. Cost-based reimbursement programs are available as Rural Health Clinics or Federally Qualified Health Centers. These often provide better reimbursement for primary care services.
Multiple foundations support grants regarding rural health education. Often a small grant will set up efforts for a larger one. A small state grant to East Tennessee State University and a concerted departmental effort to set up a rural satellite site led the way to a multimillion dollar foundation grant involving multiple sites over a period of several years. New foundation and federal grants to fund rural training appear almost quarterly. Those who collaborate with rural communities, health departments, primary care organizations, and rural providers will find themselves in a position to receive funding for rural programs.
Federal family practice grants can assist in the development of rural programs. Rural programs and emphasis have been a high priority of the grants. Program grants may fund personnel such as faculty or other providers. Predoctoral grants fund student rural experiences. Faculty development grants help faculty with rural programs as well. Some states support efforts to coordinate rural programs through state AHECs, Departments of Health, local or regional health departments, the Department of Education, regional agencies for the aging, or other health care organizations. Rural primary care research grants also support the rural efforts of faculty.
Timetable for Developing Rural Programs