Programs in Rural Medicine

Department of Family Medicine

James H. Quillen College of Medicine

East Tennessee State University

Johnson City, Tennessee

Robert C. Bowman, M.D.

1992

Physician recruitment and retention in rural areas is a well documented, chronic problem plaguing America's rural communities. Tennessee is no exception. Physicians must be properly trained to address the special health needs of the rural communities, motivated to locate in a rural community upon the completion of their training and supported in their community practice. Trained in delivering primary care to men, women, and children of all ages, the Family Physician is the one most adequately trained to provide comprehensive health care. The solution to the rural health manpower problem depends on providing properly trained and committed family physicians.

Located at the base of the Southern Appalachian Mountains in Northeast Tennessee, the James H. Quillen College of Medicine is committed to addressing the primary care physician maldistribution problem. The department plays a central role in helping the medical school meet its stated mission. The department directs three Family Practice Residency programs in the towns of Johnson City, Bristol and Kingsport. Collectively, they train 54 Family Medicine residents per year, direct a Rural Fellowship program and have a significant responsibility in undergraduate medical education. Of the 134 graduates of the department's programs, 65% have located in towns with a population of 50,000 or less.

Grounded in the philosophy of early identification and constant reinforcement of medical students and physicians in training, the department's programs are designed to have long term success in recruitment and retention of primary care providers in this region, ultimately easing the health care crisis. Within the department, these rural programs have improved the quality of medical education at ETSU, they have aided the department in recruiting residents and faculty, and they have brought national recognition to the Department of Family Medicine and the James H. Quillen College of Medicine.

 

A DESCRIPTION OF THE DEPARTMENT'S RURAL PROGRAMS

The State of Tennessee funds the basic structure of the department, but the rural programs exist because of federal funding through the Bureau of Health Professions and other entities.

Rural Health Career Fair The Department coordinates this health career fair for rural high school students from underserved areas. The College of Medicine, the School of Nursing, and the School of Public & Allied Health support the program. Originated by the Rural Student Interest Group (see below), this workshop demonstrates a variety of health careers.

Rural Student Interest Group (RurSIG) The Rural Student Interest Group supports and encourages preparation for rural practice. The group organizes the Rural Health Career Fair, provides visits to rural practices, and promotes rural student preceptorships. RurSIG is a place where students can support each other in the decision for rural practice.

Appalachian Preceptorship The Appalachian Preceptorship Program provides an unparalleled rural practice experience to attract and maintain medical student interest in rural medicine. In its eighth year, this summer program is the only educational experience of its kind, providing one week of concentrated interactive educational experiences on such topics as culture in medicine, doctor/patient relationships and alternative health systems, and three to five weeks working in a rural community with a family physician. This program is open to MS-1 to MS-4 medical students from across the nation who are interested in family medicine.

Mountain City Family Health Center The Department administers this rural, community-oriented, primary care facility an hour from the main campus at ETSU. Medical students or residents may spend one or more months learning or researching the dynamics of rural practice and community medicine (satisfying LCME or Residency Review Committee guidelines). Two full-time and two part-time family practice faculty reside in Mountain City. Housing is available.

Harmony Grocery Recruitment Dinner One evening each Fall residents and their spouses attend a special event in Harmony, Tennessee which is sponsored by the Tennessee and the Virginia Primary Care Associations. The department coordinates the arrangements at Harmony Grocery, an old country store that is now one of the area's top restaurants. The physicians and administrators from Community Health Centers who attend give a picture of rural practice and life in their town.

Rural Fellowship Program The Rural Fellowship is a state funded PGY-4 program for residents who desire additional preparation for rural practice. Fellows tailor their experience to include colposcopy, endoscopy, treadmills, rural rotations, rural program management, routine obstetrics, curriculum development, precepting techniques, and research. There are two fellows/yr.

Minifellowships in Rural Medicine In its third year, the Minifellowship trains full and part-time family practice faculty in the programs and skills needed to prepare students and residents for community-based rural practice. Each minifellow prepares a rural project - a program, satellite, rotation, or curriculum. Minifellows attend five seminars at ETSU or at national rural or family practice conferences to interact and consult with noted rural faculty and experts in rural health.

Physician Support Network The department offers teaching opportunities, faculty clinical appointments (over 60), facilitates the rural physician's recruitment efforts, sponsors CME activities, and gives practice management assistance. Residency alumni receive special support in their first years of practice.

RFD -"Rural Family Doctor" This newsletter (circulation 3,000) is for current and future rural practitioners. It contains articles on rural programs, health policy, and people in rural health.

Rural Database The Department maintains a rural database of over 5,000 people involved in rural health. The database includes rural faculty, speakers, governmental agencies, rural program directors, and others.

 

IMPACT OF THE RURAL PROGRAMS

Recruiting Students and Residents The rural programs and faculty help attract good candidates at every level to the Department of Family Medicine. Of those inquiring about our residency programs, 37% note an interest in the department's rural programs. We even receive inquiries from first year family practice residents from other programs who are interested in our rural training. This increased interest is a result of our continuing presence at the Resident-Student Conference at Kansas City as well as our networking with other family practice faculty through the minifellowship and fellowship programs. The mail-outs for the "Rural Family Doctor", minifellowship, and fellowship have also extended our influence. Contacts with program directors, faculty, and chairmen at Nebraska, Alabama, North Carolina, and other locations have resulted in many more students coming for rotations and residency program interviews.

The department's rural fellowship is beginning to have an impact on ETSU medical students. Fellows participate in the clerkship, in physical diagnosis, and in the Rural Student Interest Group. They also influence students and residents rotating at the VA and JCMCH during Obstetrics and Surgery. To them, the fellows reinforce the idea that rural practice is a worthy goal for their own medical education.

Recruitment and Retention of Faculty The Department's rural programs have been a major factor in the recruitment and retention of faculty. Five recent faculty candidates visited the department as a result of our involvement in rural programs. Four of these signed - Drs. Craven, Townsend, Chastang, and Rutledge. Our new Kellogg Director is also here as a result of rural programs. Faculty recruiting takes on increasing importance with the Kellogg effort.

ETSU as a Medical Education Leader in the State and Nation At the state level, the department has coordinated two Rural High School Health Career days. Students from health manpower shortage counties of Northeast Tennessee were invited to the ETSU campus to learn about the wide variety of careers available in nursing, the allied health professions, and medicine. Several students did not know that ETSU had a medical school until they attended the fair. Rural programs have assisted Mountain City, Rogersville, Erwin, and other rural communities and physicians. The future funding of the medical school may depend on successful efforts in this area.

The department's rural programs (the Health Career Fair, the Rural Student Interest Group, the Rural Fellowship, and the Minifellowship) have been listed in publications by AAMC, AAFP, STFM, NRHA, and the American Hospital Association. The department received awards from both Virginia and Tennessee Primary Care Associations for excellence in rural health education. The rural programs have been a factor in ETSU's acceptance by Kellogg as a program site. In the past few months the rural office has received increasing inquiries from physicians and residents seeking advice on how to handle the special demands of their rural practice sites.

The minifellowship sessions have been a culmination of years of work by rural faculty. Minifellowship Session III, held here in Johnson City in November, 1991, has been approved by the AAFP for fourteen hours of prescribed CME credit. The minifellowship faculty now advise five residency programs directly and indirectly another ten.

The Rural Student Interest Group and the Rural Faculty Development programs are a model for the nation. Rural faculty at ETSU and this year's minifellows are preparing a rural curriculum for the Society of Teachers of Family Medicine. A survey of rural faculty nationwide will define the role and scope of rural faculty. Dr. Bowman is currently a co-chairman of the STFM Group on Rural Health, working with a steering committee to guide rural medical education throughout the nation. Dr. Bowman's selection as a Public Health Service Primary Care Fellow is another honor for the department as well.

Improvement in Quality of Education at ETSU Our rural programs have attracted top rural medical education experts over the past two years. These include Tom Rosenthal, M.D., who directs the Office of Rural Health at SUNY Buffalo in New York, and Jack Verby, M.D., who directs the Minnesota Rural Physician Associate Program. A frequent speaker is Bruce Behringer, currently the president-elect of the National Rural Health Association. Other experts speaking at the minifellowship sessions include noted rural researchers Roger Rosenblatt and Tom Ricketts, rural health policy experts Jeffrey Human and Don Weaver, family practice and rural medical educators Bob Walker, Mike Sitorius, Kevin Fickenscher, Tom Johnson, Eva Salber, and Harvey Estes.

Ideas formulated by attendance at National Rural Health Association meetings, HRSA meetings, and STFM have been communicated to other faculty in all health science divisions. Minifellowship speakers have discussed medical school planning with the dean on two occasions (Kantrowitz and Verby). Faculty networking with other primary care schools and leaders have planted their ideas in the fertile ground of the Mountain City Family Health Center, the Minifellowship, the new Northeast Tennessee AHEC, and the Rural Primary Care Track.

Ties Forged Between Family Medicine and the Divisions of Health Sciences The rural programs and faculty at the department have been working hard to foster joint endeavors with the other health science divisions. Rural programs and faculty have cooperated with the School of Nursing through the Mountain City facility and the Homeless Clinic. Rural faculty taking M.P.H. courses have connected with Allied Health resulting increased learning opportunities for students and faculty. Rural faculty and staff from Medicine, Nursing, and Public & Allied Health organized the Rural Health Career Days in 1990 and 1991. This initiative established a base for an April 1991 meeting of all health science personnel involved in rural programs. At this meeting faculty met one another and laid the groundwork for some collaborative work in program development and research.

Rural Communities Involved in Rural Medical Education The work of Drs. Burkett and Beck (Division of Research) in conducting the ongoing Johnson County Health Survey has also been significant in removing barriers for the health science divisions as well as improving university-community relations. Bruce Behringer, the new director of the Kellogg Community Partnership training program, has continued to organize and direct these early efforts. This involvement is the key to health systems change. Communities like Mountain City must work more closely with the state and medical schools to help meet their needs.

Rural Programs Support and Connect Faculty Rural programs support several past minifellows and current department faculty. New faculty have faced tough times in Mountain City and at the residency programs. The minifellowship has been a major source of orientation, guidance, and support for four faculty during their first year as full-time teachers. Rural meetings connect them with the university and department.

Liaisons with Rural Health Centers Through the rural programs, the Department has built a significant linkage with rural physicians and Community Health Centers. The Appalachian Preceptorship involves a network of over sixty of these physicians who volunteer time to teach at their practice sites. Some rural and CHC physicians precept at the residency programs. Five ETSU faculty have come from Community Health Centers. The ETSU faculty have placed over thirty residents in Community Health Centers or Health Professions Shortage Areas. Last year ETSU faculty served the community of Dungannon for most of the year until a full time physician could be recruited. Nearby rural hospitals and CHC's have an open door policy for recruiting residents. Rural faculty regularly give seminars on recruitment, retention, and faculty development. They offer consultation to new rural physicians, hospitals, and centers.

IN SUMMARY, rural programs are an integral part of the success of the department and the medical school. They also have an impact on rural communities, the state, and the nation.

 

THE FUTURE AND RURAL PROGRAMS

To Further Assist the Department and Medical School:

1. The fellows and Dr. Bowman will increase their contacts with the residency programs and future Kellogg expansion sites. This will connect the fellowship with the programs and better prepare the department for additional rural sites. Specifically, the Rural Health Office will assist the program directors in establishing a rural presence and improving the procedural component of the residencies so that we can continue to attract, sign, and train the best rural-oriented residents in and for the country.

2. The minifellowship will include faculty from Mountain City, Rogersville, Madisonville, and/or Cocke County during the 1992-93 session. This is an important part of the effort to develop Kellogg faculty.

3. The rural office will prepare articles and presentations for the TAFP and TMA.

4. The funding for rural programs could further assist the department in its goals. Rural funds could support an annual conference for the Department of Family Medicine at Johnson City rather than sending fellows to courses elsewhere. The fellowship would then benefit the department, the programs, the faculty, and the residents. Contacts with procedural faculty such as Dr. Stockton at Knoxville, faculty at Memphis, and AAFP directors have laid the groundwork for this effort. This would also allow significant networking between nearby rural practitioners and the department and medical school consultants.

Important Possibilities for the Department Because of Rural Programs:

1. The department is in a position to discuss important issues of health systems (CHA, health department colposcopy, loan repayment and locums), reimbursement, indigent care, recruiting, faculty development, AHEC, CME, and other areas with the other family practice programs in the state. The common ground of rural programs and rural need would bring the programs together.

2. The department could become "the" major advisor for the development of rural programs and curriculum. The department now has that opportunity at the Rural Theme day of the STFM Annual meeting when Dr. Bowman presents the rural curriculum. This curriculum is the product of the minifellows and rural faculty at ETSU.

3. The department could pursue designation as a national or regional rural faculty development program. This would involve funding from the Public Health Service and major foundations.