This is a good question, my answers from 2003 and 1992
enclosed:
2003 - In order to discern who is really interested in rural or not, it takes
detective work. This might be difficult for the more amiable types on admissions
committees. Admissions committee members who are experienced in rural lifestyle
will have little trouble (especially rural community members, rural docs, etc.).
Others can ask the following:
You start by finding out what the student likes to do, and then later you ask
how they plan to do this thing that they will do, when they are in a rural area
in practice.
If they have this worked out well, then they have given it some thought. The
answer is not as important as the impression of whether the student has thought
about this before and is comfortable with this.
The point is that students who are interested in rural practice have a framework
that they use to hang things on, like recreation, training, location of college,
and even spouse interests. Those without such a framework are unlikely to endure
the gristmill of current medical education and come out less than fairly
scrambled in thought, word, and deed.
One caution, the rural students or those from less than secure backgrounds may
also be fairly uncomfortable with any questions, particularly some personal
ones. Be sure to try to separate discomfort with the whole vs that of a part of
the interview.
Also you can make a case that those who say they are interested in rural
practice that look to be lying, might not be the most desirable, although the
pressure to get in is enormous. Still this might make it easier to separate the
two groups with a little prodding. Perhaps some insider approach might work such
as "You don't really want to go out in rural practice, it is so ....... etc. And
see what happens
Don't like the probing, but sounds more and more like we need
to probe folks before, cause too late after.
Robert C. Bowman, M.D.
Training for rural and underserved areas February 3, 1992
I was glad to see your letter regarding innovative residency training. I see this as part of the solution. Although I am enthusiastic about the many new initiatives in medical education, I feel that we expect too much from them.
It seems that we continue to identify problem areas in medical education. With each problem we try a solution. In typical American fashion we then expect this singular effort to "fix it". Simplistic solutions have not worked in the past and will not work in the future. Nonetheless, each potential solution, when added to others, can build a comprehensive approach. It is currently not possible to perform major surgery on medical education, but we can patch it up to perform better.
Let me approach this problem with a few true stories.
The first story comes from my rural practice in Nowata. I met John and Roger as the top science students at Nowata. Both are interested in medicine. They were receiving recognition from the county medical society. John is a junior in high school. He is the high school quarterback, the president of the Fellowship of Christian Atheletes, one of the most popular students, and holds a 3.7 GPA. Roger is a senior, has a 4.0, is doing research in Oklahoma City in the summers, and knows few students. When I look at who is likely to enter medical school, it is not hard to see Roger accepted. John may have difficulties. It seems that we have a lot of Rogers in the system already. They work alone, they can take abuse, but they can also produce problems. I think that John is much more likely to go to a rural place like Nowata than Roger.
Tim is a first year medical student. He has been at work or at school for several years. He is rich in life experiences. He is 35 now, the first in his family to make it to college. Jeff is 23 and the son of a physician. He really is not sure why he is in medical school. Maybe it is what was expected. Tim expresses a sense of frustration that Jeff and many of his classmates do not understand that medicine is a service profession. Many accept the academic or personal challenges, but seem to miss the devotion to patients. I hope we learn to pick more Tims in the future.
Sarah is on her third year clinical rotations. Her write-ups are excellent yet her slow methodical style leaves her open to interruptions by others. Her grades reflect neither her superior knowledge nor her excellent habits. No one bothered to tell her that she is an SJ (sensing-judging) type personality in a world of intuitive types. She loves details and completeness in an academic world where patients and students fall through the cracks. Sensing types make great rural and primary care physicians. They work methodically. They enjoy the routine. They are less likely to pursue the strange and exotic diagnoses with expensive tests. We need more doctors like Sarah and we need to support the Sarahs in the system.
Byron is a senior on the interview circuit for a family practice residency. He comes from a primary care-oriented school. He has an obligation for serving the underserved. At his interview I ask him if he knows whether he is interested in a profit or non-profit type career. He did not know about Community Health Centers or any other type of health center. We talked about his needs to communicate with patients and deal with their health maintenance needs. Byron did not come to our residency, but he knows enough now to arrange some time in Community Health Centers.
I could tell you about the hundreds each year that are turned away from rural and underserved experiences because of too few positions.
Why is it that the students in Christian Medical and Dental Society are the same ones in our Rural or Family Practice Student Interest Group with many overlapping into the Student Alliance for Global Health or the Sharing Clinic or AMSA?
Can we pick students for altruism and service motivation and likelihood of rural practice? The literature says yes, yet we do not. There are candidates from other serving professions and others who are leaving other professions because they lacked service. Other students have religious motivations or a record of service to community. Admissions committees that have rural folks as members do a better job of choosing those likely to go to rural practice eventually.
I think we know what needs to be done. We have programs that address our needs. What we lack in medical education is coordination of these programs.
We need someone to identify, encourage, track, and advise students who seem to have "the right stuff". This would involve people in communities who are underserved. They would identify the candidates. For example, rural physicians would work with the schools to identify service-oriented students. The program would encourage the best from rural and urban areas, those with the desired personal and academic characteristics.
The program would extend throughout medical school and residency and into practice, offering advice, service experiences, and counseling. Groups of students who are accepted into the program would meet yearly or more often, encouraging each other to continue the mission of the program.
The closest such program is in Kentucky at Hazard. Students never leave the region throughout their college and training. Minnesota combines the Duluth and RPAP programs to capture more rural physicians. Students from urban and rural backgrounds receive 9 months of training in rural medicine, the doctor-patient relationship, and more. Even urban background RPAP students choose rural practices. RPAP's graduates have improved residency training programs and helped to establish more viable systems of care for rural areas.
Combining features of the above two programs and adding a support package for those in practice would come the closest to a comprehensive program of training physicians for service to the underserved.
Initially the program would have to be experimental, moving beyond the current literature with trials of selection extending to the high school level.
Years of training students and residents in urban subspecialty locations has produced many subspecialists. This is a simple statement, yet it reflects the difficulty of changing the training methods. Change is needed in several areas. The reimbursement design needs far more emphasis on primary care than currently planned. Many target curriculum reform as a major goal. I believe that attitude change is far more important.
Medical education needs to be student-focused rather than professor-focused. If learning and competence is important then small groups and preceptor methods should be emphasized. These support students, emphasize teamwork, and verify education. This seems much more important than how many students can fit in a lecture hall and how much can be crammed in per unit of time. Computers and audio-visual aids in medical education should allow far more individualized instruction. Students are hungry for the ability to care for patients. This is one of the strongest motivations and one that is poorly utilized.
The leadership of medical education lacks vision and knowledge of the nation's health needs. Far more pressure needs to be exerted for change, the leaders must change, or a reformed type of training created (see below). The environment of the training must change. Practicing primary care physicians must be the major part of the curriculum. Other physicians or professors who teach students must understand that the mission of the education is to produce physicians for service.
Many medical schools approach such a model in some areas. What is needed is a comprehensive approach to education. With effort the current system could prioritize the admission of primary care underserved-oriented students. It could change the curriculum and environment and faculty. Another possibility is to reform the system, starting with three years of medical school, three years of primary care residency, and then requiring three years of primary care service before specializing. This new type of training absolutely requires admissions to choose ONLY those interested in primary care training. The major change of this system is in attitude.