Quality of Rural Preceptorships
Rural Training in Family Medicine
THE PRECEPTORSHIP MODEL Preceptorships trained 90% of American doctors until the early 1800's. Without strong leadership, medical education drifted in the direction of education by enterpreneurs. Perhaps we have drifted that way again. One could debate whether today’s medical centers are devoted to patients or enterprenuereal enterprises. Back in the 1800’s Concerns regarding the resultant loss of quality in education led to major changes in the process of medical education. The German "university" method became the standard. Many students received instruction from one professor at one time. Students had to be extremely talented and autonomous. Classes were held in the classic pits with students piled on top of one another into the far reaches of the dark. This style limited the responsibilities of the professor, reduced the costs of medical education, relegated the student to a third class citizen, and sowed the seeds for the crisis in health care that exists today.
RETURN OF THE PRECEPTORSHIP Wisconsin, Vermont, and Michigan re-established "preceptorships" in their current form by the late 1920's. Depressions and the WWII forced preceptorships into dormancy. They emerged after the war. Seventy per cent were in public medical schools. All 8 mandatory programs were in public schools by 1970 (the above from Steinwald and Steinwald, Medical Care Vol. 13, 1975). As the public perceived the loss of rural physicians to be a problem, the family practice movement grew. Departments of Family Medicine flourished. Emphasis on preceptorships had a limited revival in a few schools. UNMC Celebrates 50th Year of Preceptorship
Preceptorships exposed students to primary care, improved relations with rural physicians, and (hopefully) increased the probability of a rural decision. By 1964 there were 34 preceptorships (26 elective, 8 required) in the 84 medical schools involving 1000 students. Seventy per cent were in public medical schools and all 8 mandatory programs were in public schools. Almost all were 4 - 12 wks usually in the 4th year. (the above from Steinwald and Steinwald, Medical Care Vol. 13, 1975)
Modern medicine is fixated on quick and easy answers from interventions. This includes medical treatments as well as societal. Preceptorships have not been the answer, but they have certainly been a key component in programs that have graduated rural physicians. Most studies of preceptorships have had little personal information on the candidates (rural background or not) or data on the content of the programs (service, clinical). Many preceptorships have been elective.
LIMITED PRECEPTORSHIPS PRODUCE LIMITED RESULTS Despite the revival, the total curricular time for such teaching was only 4-8 weeks. This was mostly in the final year of medical school and often after a career decision had been made. With such a limited role in the curricula, it is no wonder that the data from studies of the impact of departments (WAMI impact paper) and preceptorships (Pathman) is mixed. The data are further confounded by lack of information on the candidates or the content of the programs. In general the typical limited rotation seems to do little more than to influence the few remaining undecideds.
When loan forgiveness programs have been instituted without any other strategies, the results have been dismal. But when they have been combined with other efforts, such as careful selection of candidates who are motivated to work in the areas of need, specially designed teaching experiences, and counseling and placement services, they have been quite successful. Southern Regional Education Board 1983
PRECEPTORSHIP TIMING AND INFLUENCE A 4th year preceptorship is too late. Nebraska's change from 4th to 3rd year seems to influence 2 or 3 students a year. The change also demonstrated that the preceptorship was voted the best educational experience in both the 4th year and then the 3rd year. Arkansas moved their preceptorship before the start of the 3rd year and felt that this was a good position, a position also held by Mercer.
In general the typical, stand alone, 4 week rotation seems to do little more than move the undecideds to urban or rural. Background of the student and spouse, specialty choice, and program location seem stronger factors. A strong, charismatic preceptor can have significant influence, especially early in the curriculum.
Preceptorships with a special design can be helpful. The APPALACHIAN PRECEPTORSHIP is a fourth year preceptorship for students from all over the nation to explore Appalachia, rural medicine, the community oriented approach, and more. This program has assisted ETSU in attracting residency candidates as well as physicians for the area.
The quality of rural preceptorships is equal to or greater than traditional training.
The data from studies of special preceptorships or long term programs is much more positive. These preceptorships train better medical students, giving them much more skills and confidence. This is probably not because the rotation is rural so much as the setting leads to more one on one education and the ability to actually do things when compared to most academic settings.
Changes in accreditation would help to establish preceptorships. The documentation of the quality of education for preceptor students is among the best in medical education. Changes in curriculum would also help. There is unfortunately little support for faculty who are planning such preceptorships. Near miracle situations created the current preceptorships (Verby) Other resistance for the preceptorship model comes from a strange source. Foundations pushing new models have precluded preceptorships - one of the few proven methods for getting students into rural practice. Many have been more interested in interdisciplinary programs and improving nursing and public health, rather than focusing on medical education.
RURAL PRECEPTORSHIPS, details and examples
RUOP WWAMI and Long Term Effect of FP Curric Pathway
Mercer - reaching out to rural regions, networks http://www.mercer.edu/publications/Medicine/fall99/pg6.html
The Rural Alabama Health Alliance
UNMC Students Same the Rural Family Practice Preceptorship the Best 3rd Year Rotation
LCME and Florida State Medical School
Why does rural fit in with medical education.
A study of the best models for training and retaining physicians for
underserved areas from MGT to FSU
http://med.fsu.edu/pdf/02_train_retain_phys.pdf