Back to Objectives for Rural Programs and Curricula
Clinical competence is certainly a primary goal of all residency training, but it impacts on rural medicine much more heavily. If physicians do not feel clinically competent, they will not be comfortable in rural areas where they tend to be more on their own. Simply stated, without a general feeling of competence, physicians will not pursue a rural location or stay there long. Also if they do not gain competence in a reasonable time, they will be using precious time in their last 2 years of training when they should be spending time on critical areas such as courting and choosing a practice site, preparing their family for the move, examining the relationships between practice and community and management, gaining cultural awareness and competency, gaining clinical confidence, tailoring their training to the specific needs of their practice site.
Ideally the learner, whether student or resident, will be fed responsibility for more and more complex patients and situations at a level that challenges them throughout their training, thus developing maximal competency.
Some of the more innovative programs seem to emphasize this Meeting the Needs of Underserved Rural and Inner City Areas with Accelerated Graduate Training
Rationale and Description:
The definition of competence is appropriateness, fitness, suitability. First and foremost rural physicians must be good clinicians. They must be able to acquire and process information. Rural practice is the broadest and truest form of primary care. Rural physicians go where no specialist has gone before. Those preparing for rural practice should utilize all seven years of medical education. Attaining competence is not limited to training. Once in practice, rural physicians must learn about referral networks, community resources, and opportunities for continuing education. The pursuit of competence is a relentless task.
Rural practice demands a broader perspective on medicine in an environment where physicians are extremely visible to peers, patients, staff, and others. Their financial success and status in the community is in some measure determined by their competence. Rural physicians must be competent in areas beyond biomedicine. The demands of the generalist environment, the "buck stops here" primary care role, the community perspective, psychosocial needs of patients, and the enhanced doctor-patient relationship all extend the need for competence in many areas.
Subject areas:
The priority for study is ambulatory primary care. The curriculum must cover the basic clinical skills and routine ambulatory procedures. Problem-solving skills are critical to rural primary care. At the student level physicians must learn to gather information efficiently and continually review the diagnostic possibilities. At the resident level physicians should be alert for unusual patterns or presentation which would demand further inquiry. They must be able to analyze the information to come up with a plan of action. They must learn to treat those with emergency needs promptly, delay care when not yet warranted and/or more information is needed, or utilize referral sources when necessary. Training programs should concentrate on these areas. Faculty advisors should review the individual progress of trainees and institute planning Rural physicians must continually train to keep up knowledge and skills. Rural physicians should utilize several methods of continuing education using reading materials, meetings, weekend courses, computers, utilization of consultants to expand the level of knowledge, academic contacts through teaching, and blocks of time as necessary for periodic comprehensive review or the development of new skills.
Methods:
Training that involves "hands-on" responsibility is essential. Appropriate responsibility forces the pursuit of excellence in clinical care. The "buck" may not ultimately stop with the student or resident, but the physician role can be effectively shared or delegated. "Hands-on" training prepares students and residents to be competent. Using Your Residency
Supervision is always a necessary component of medical training. Appropriate supervision and teaching encourages trainees to expand their knowledge and self-confidence. Too much supervision inhibits clinical responsibility. Lack of supervision can cause problems with self-confidence. Low confidence levels result as mistakes are made or trainees are not pushed to their limits. Lack of supervision can cause some trainees to become overconfident and/or unresponsive to critical review of their care by self or others. There is a tendency for those with a need for more supervision to avoid supervision, chosing programs or electives to satisfy this need. This points out the need for an active advisor system. Rural physicians tend to go to areas where there is less supervision, less peer review, and more autonomy. It is essential that physicians preparing for rural practice develop confidence and the ability to accurately assess the limits of their skills.
One on one relationships with quality rural preceptors greatly facilitate learning. Students should also have access to other physicians to compare and contrast different clinical approaches. The major value of the preceptorship is in the preceptor's "ownership" of the student. When preceptors have the time and interest to invest in the student, students learn a tremendous amount, including more than biomedical information. A preceptor can keep up with the day to day learning process of a trainee. Preceptors do not rotate off the service every week or month. With some help on good teaching habits, preceptors can give valuable on-going feedback to their students.
Peer to peer interactions are important. Training programs should encourage discussion of cases with other trainees and faculty. Consultants are another important resource. Some of the best training occurs when learning focuses on patients in the care of the trainee. Advice by consultants over the phone, at the consultant's office, by mail, or at educational meetings helps physicians to improve care as well as their knowledge base. More importantly primary doctor-consultant communication can help physicians realize their strengths and limitations. Unfortunately much consultant utilization at training programs involves transfering care or the responsibility of physician orders to consultants or residents working with the consultant. This bypasses the primary care physician's ability to customize the orders and optimize the care, utilizing his or her extensive knowledge of the patient's past medical history, personal and family resources.
Examples:
The Rural Physician Associate Program (Jack Verby founder) in Minnesota fosters "hands-on", ongoing supervision, one on one precepting, and peer interactions. Minnesota's Rural Physician Associate Program is the nation's premier program. Its success is measured in the 58% of students who practice in rural locations (national average is 6%), the 341 out of 545 who entered family practice (1991 Match at 10%) the demand for the clinical preparedness of the RPAP students by family practice residencies, the spawning of at least three other RPAP like programs, and equal or higher scores for RPAP students in clinical skills (26/29), behavioral skills (4/18), and professional skills (3/7).
RPAP students spend 9 months of their third year (first clinical year) in a rural area with a rural preceptor who most likely is a former RPAP student. Longer rural experiences give students an opportunity to learn much more than biomedical information. RPAP students and their spouses move to the rural area. Students start by observing their preceptors and meeting the other health providers in the community. They see patients, read, and work with faculty from the medical school on videotaped encounters, medical interviewing, and clinical information. Specialists work with the students at their home sites. Computers connect the students with information databases and the home medical school. RPAP students know their career options, referral resources, and the issues regarding balancing careers and families much better than non-RPAP students.
Rural Preceptorships often aid in the development of clinical competence as they get trainees away from multitudes of staff, residents, and other students. Freed of competing entities, students may work one on one with patients and preceptors.
Veterans Hospitals and some urban county hospitals offer "hands-on" education in exchange for the responsibility of service. Rotations at these institutions can be valuable, but supervision and support for education is the most important component.
Quality in Rural Medical Education
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