From the medical student point of view, there doesn't seem to much support or respect for the student wanting to do rural medicine. That is, the specialists in the tertiary centers and even other medical students frequently respond with something like "you only want to do rural medicine"? I grew up in a smaller town and have observed that the rural family docs seemed greatly respected, which is why I think I can safely dismiss the frequent discouragement. As the experts on rural medicine point out, not many medical students from an urban background go on to practice in rural areas. It seems easy to see why, when one hears the frequent stories starting with "you won't believe what the rural doc from x northern town missed..." resonating in the ivory tower. These stories and a lack of any idea what real rural practice is like probably make a lot of medical students decide that rural medicine is not likely their higher calling.
Lisa Friesen
Med III UBC
Robert Bowman wrote:
Dr. Bob Boyer, a rural physician in Kingman KS for decades and the first AAFP doc of the year, answers this question far better than I when he talks to medical students and residents at the AAFP Student Resident meeting in Kansas City each year. He outlines 4 obstacles to rural practice, many if not all have been illustrated by previous list serve examples:
The 4 Obstacles that (non-rural) people with tell you
Bob negates all 4 with true stories from his rural practice.
I graduated from Medical College of Virginia two years ago. My class was the first to experience a new program where we actually got clinical experience (how to do an H&P; how to perform clinical exams, actual time working in a physician's office, etc) during the first two years of med school. While it was useful for any specialty and made us better prepared for the clinical years and gave exposure to peds and internal medicine as well as FP, it was perceived by the students as "primary care being forced down our throats" and an attempt to "turn us all into family practitioners." Not surprisingly, the percentage of folks in my class who went into primary care, much less FP, was lower than usual. An example of how "the environment" of medical school was seen to have a negative effect on future decisions to pursue primary or rural health care. How much of this impact was because we were the first class to try on a new program is not clear.
I find this a very interesting and important discussion, and I echo many of the issues already stated. Certainly, there are the two related issues:
first, choosing primary care, then secondly choosing rural practice. I think that the first is as important ( if not more so), because it probably happens sooner in the pipeline. Thus, the medical school environment is very important. I graduated Univ. of Arizona, where the entire clinical curriculum in the first 2yrs is ran by the FP dept. They had such exposure, that it highly influenced the students decision on specialty (>70% went into primary care my year). I would be interested to know more about schools' environmental effect on decisions.
Mike Kalsman, MD
SUNY-Buffalo Rural Family Practice Residency Program
A couple of thoughts about the quality of teaching Family Medicine in rural vs urban settings.
As a graduate of a rural track program, I have found that I did have in many settings the benefit of being trained without having the competition of other specialty's residents. Those experiences have gone a long way to ensure my competency as a rural physician and my interest in maintaining a broad scope of practice, including OB. When you have a rural physician of another specialty taking the time and effort to train you as best as they can for what they understand may be your most challenging roles within a rural setting, you come away with more than competent skills. When a preceptor provided me with that opportunity, not because it is a requirement, but because they appear to care about me as a learner and about the patients I will be taking care of, I no longer felt that I was put just to do busy work or that learning was a chore - I was being offered a gift.
I learned that in rural settings often communication and cooperation across specialty lines becomes the crux to providing high quality care and to the survival of healthcare in that community at large. But not only is it a necessity, it becomes part of the fun of practice of medicine to be able to collaborate and make a difference.
With medical students coming to such an environment, it won't matter in the end if they become family physicians. I always hope that the experience ultimately will make a difference in the way they pursue their professions and relate to their patients and peers.
To get back to the urban vs rural training setting: I think that an urban setting can train very fine rural physicians. However, as a resident who plans to practice in a rural setting, it is least helpful to hear attendings criticize the lack of skills that brings a rural patient to a tertiary care specialty setting and then, simultaneously, not being taught, as a resident, the necessary skills to do better. On the other hand, residency won't be able to teach you everything you may need and some of what you learned you may never use. But much of the success in training may lie in the informal training that students and residents receive. This is not a difference between urban or rural settings - it is where we all can do better and be more successful as teachers and role models.
Students/residents come to us to learn how to take care of patients; medical training is still tough, frustrating, and a long process - it requires a great deal from the learner, including putting off lots of things because of the perceived wonderful outcome of finally becoming a practicing physician. Exposure to an environment where people waste energy on intra/interdepartmental politics, specialty turf battles, or an environment where patients constantly express frustration with the lack of compassion or continuity of care, ultimately erodes that sense of purpose that has to be the basis of why we are doing this.
Probably no other specialty better than Family Medicine is prepared to focus on the essentials: the patient and how they connect to their social environment - their family. It does not matter whether the FP or the surgeon or the internest does the flex sig if the patient in the end is served best.
However, if you are the only doc or one of the few docs to be doing the procedure, it will be very important that you learn to do it well. This is where continuous education in procedural skills remains important. This is THE OPPORTUNITY for tertiary care settings to help improve the quality of care out in rural areas...How about tertiary care/teaching faculty providing "locum tenens" services or weekend workshops/training for those rural docs who desire to upgrade/refresh/expand their skill levels...some residency teaching programs already do so.
But let me turn it around...how about a trade off where teaching faculty has an opportunity to train with rural physicians to maintain their skills. I tend to think that it would be easier to have a rural OB/GYN let you scrub in for while to do C-sections than asking the OB/GYN department unless you have an outstanding relationship with that department.
I most certainly enjoy the dialogue on the NARME list serv as the list serv shows to meet a real need to start and continue dialogues about important issues that touch us all. Thanks for giving me the opportunity to participate.
Sabine Maas, MD