Jeffrey Stearns, M.D.

Associate Professor, Family Medicine

Director, Rural Medical Education Program

Formerly at the University of Illinois College of Medicine, Rockford

I am going to pick up because now after Tom’s talk we’ve selected all the right stuff to go into medical school. Those of us who have to deal with a lot of educational programs for students once they are in medical school are very concerned at looking at the pieces of that four-year curriculum. We all recognize it is not particularly a user-friendly process--medical school--that we have a variety of folks who come in with very good intentions, and when we look at the end of that four-year experience, that what may be a reasonably good stream going in is often a trickle coming out at the other end. Our concern in the medical school education is

How do we keep those people focused and on line and give them the support?

One of the things that we have done within family medicine in the past year is send out a survey to all the folks in medical student education to look at what the schools are doing at least within the Family Medicine Department with regards to rural education. To date, we have back a response from almost 70% of the schools. We posed a variety of questions, at least in a preliminary one.

Most of you who have experienced sending out mailed surveys, the response rate tends to be--if it requires much work--fairly low. We wanted to initially define the universe of folks who have an interest and a focus on rural education. So we posed questions like, "Was there part of the school’s mission statement that had to do with rural?" and "Was there part of the Family Medicine Department’s mission that had to do with rural?" And you see that almost half the schools would respond "Yes" to the rural mission. At times, I am skeptical of that; nevertheless, at least it is a reasonable number to start with. A much higher percentage of the Family Medicine Departments, again, probably not unexpected, responded that part of their mission had to do with rural.

If we take and break them into the following categories, the first being "Did both the school and the department have a rural mission?" 46% of the schools said that they did. Then we asked, "Do you have specific courses that have to do with rural medicine?" Then, "Are they required courses, elective courses, or do you have both?" Then at the bottom, the spread of where they take place. It clearly is a concern that you must keep after the students, support their choices, and keep them focused on what the goals are continuously through a process. You see that there is a variation on not only which years the courses take place but the length of time. Maybe most importantly for the next phase of this study is 59% of the folks that had specific rural courses have written curriculum. It will allow us to then go and see if we can make some correlation to help all of us in terms of what we should be teaching, and it will be something that Deb will talk about later--that we have the ability to put it up on the Website that we use for rural health. If the school does not have a rural mission but the department does, it is split about in the middle whether they have specific courses.

What is discouraging is that now all the sudden you see that none of them are required, and they are all elective; although encouraging a little bit that they are scattered over the four years. Interestingly, within this group they are much more likely to have a written curriculum, which is certainly encouraging. If the school has a rural mission, and the department does not have a rural mission, my first question is Who filled out the questionnaire? But this is what this looks like: two of the three do have specific courses. They are, again, elective, but they also have written curriculum, which is certainly a start. Finally, the ones that answer, "No," "No" on the questions, they responded that they still do have some specific courses in rural--one is actually elective, which, again, I wonder who filled this questionnaire out--and they are required, and they are scattered elective things, and they also have written curriculum, so again it fills out the universe.

At this point it is encouraging at least if one suggests that to get people through the gauntlet, you have to have encouragement and support through the four years, that at least half of the school do have a rural component to their mission.

Frankly, there were very few surprises--the urban schools, the private schools, are much more likely not to have rural as a mission, and the public schools were more likely to have rural as a mission. You see the required courses in those that have congruence between the school’s mission and a department’s mission. Two-thirds of the ones that have specific rural courses do have curricula. There are a variety of lengths of time of courses and placement in years. The next step in this particular survey is to really start the process of correlation and come up with some blueprint for

What should people who have rural curricula be trying to focus on?

There will be some interesting correlation when Dave approaches it from a residency, which is the next piece in the pipeline.

The RMED Program at Rockford

The other thing that I want to spend a couple minutes talking about is the specific program that I represent because we have tried to take the kind of information that Tom has in terms of the admissions piece and overlay it--get the students in--and then put them through a four-year curriculum. So the University of Illinois College of Medicine in Rockford does have a state-supported specific program, which has a separate admissions track, where we try to select the right people as other people have defined through a secondary admissions process, using markers that Tom and others have defined. They are actually chosen by a panel of folks from the rural community. Those of us in academia try to pick the right stuff on paper, but they come in and are interviewed by people from the community themselves. We have rural physicians, P.A.s, hospital administrators, farmers, former dean in the School of Agriculture, some rural health clinic and public health department type people, and they actually make the choice. I think that it is a good triangulation of folks with looking at different aspects of it.

Then they go through a four-year curriculum, which during the first three years is supplemental in the sense that they have the regular medical school curriculum, but we have regular monthly opportunities to interact with them and build in curricular pieces so that it keeps their eye on their focus. Maybe more importantly, medical school is traditionally very good at educating clinicians, but what they miss is the piece that has to do with the community and how the physicians function in a community. You all recognize that if you do not understand the community and where you function, your ability to effectively deliver care, not in congruence with the community is much hampered. So we specifically focus on what rural communities are like and what goes on there to build additional series of skills on the part of these student so that they can function in the different roles that physicians play when they go out and work in the rural communities. The culmination is actually a 16-week required clerkship in the fourth year, where they go out and live for four months in the rural community. They are expected to spend one-half to two-thirds of their time doing clinical things, but they have a couple of very specific rural projects: one is a COPC project that is defined and they work on getting it together so they can enact it in some ways in the rural community during the third year, and the second is actually defining the rural community: what makes it tick? what are the industries? what are the educational backdrop? how does the hospital and the community interconnect? So they begin to discover those links, which I think are very important for successful positions in the rural. I think with that as sort of an overview, we will now look at the next piece in the pipeline, which is when we send them out into residencies. What is going on in that next piece of the link?