The 2001 Outstanding Rural Health Program Award of the National Rural Health Association was awarded to the Department of Family Medicine at the University of Nebraska Medical Center
Wayne Myers, President Elect of NRHA and past director of the Office of Rural Health Policy, agreed with this nomination in his award presentation. He noted how unusual it was for a department or medical school to make this kind of effort.
The NRHA Program award attracts competition from a variety of areas, include state programs, educational efforts, hospital programs, and various health professional programs. Duluth Family Medicine has also been honored with this award in the past.
This was the nomination submitted by Dr. Robert C. Bowman:
The Department of Family Medicine at the University of Nebraska Medical Center is my nominee for the Outstanding Rural Program. The Department is a model of excellence, innovation, cooperation, and leadership in rural health and rural medical education throughout the state, into the midwest region, and across the nation.
The primary focus of the department is better health for rural Nebraskans. Most programs would be satisfied with 40% of its graduating residents choosing rural practice. Having 40% of the third largest family practice residency program in the nation choose rural practice would seem to be enough, but not for this department. Nebraska is a state with 40 counties with less than 10,000 people yet still a doctor and a hospital. These smallest health systems provide the most difficult recruiting challenge for physicians. In a recent address, the President of the Robert Wood Johnson Foundation challenged primary care educators to deliver the kind of competent caring physicians that are needed in a variety of locations and practices. The department has long realized that Nebraska’s rural communities need more than just an average practitioner. This means a total commitment to getting the right people into medical school and training them well throughout medical school and residency.
No other academic Family Medicine program in the nation has dedicated its graduates so completely to rural training. The department converted 12 out of 16 of its first year residency training positions to rural track positions. In recent years directors dedicated 2 of the remaining 4 positions to a new urban underserved Hispanic clinic track. The result has been more graduates into rural locations and much more specific preparation for rural practice. The department is also beginning to see more difficulty in finding positions for graduates in rural Nebraska. This is indeed a unique complement for any department. The rural training tracks graduate 80% into rural practice while the accelerated residency training program graduates 70% into towns of less than 5,000 people. In order to train and place physicians where they are needed, the rural training tracks are dispersed throughout the state. Soon the department will have a fifth rural training track that will serve one of the few remaining areas with a shortage of physicians. The accelerated residency training program concludes with a rural fellowship year to allow residents to train specifically for the town where they will practice. These programs have graduated family physicians that are exactly what rural Nebraska needs. See Nebraska program and models
This excellence has been the result of leadership in rural medical education. The rural residency programs have been the result of dedicated effort by the chairman, Mike Sitorius, and the Program Director, Jim Stageman. They have worked closely with the Office of Rural Health and state leaders such as David Palm and Keith Mueller to develop a long-term plan for rural health. All realized that the shortage of well-trained rural family practitioners was a top priority. The situation just a few years ago was a difficult one. Good quality students were leaving the state for other residencies. Family Medicine nationwide faced challenging problems attracting enough students, much less the kind of students who were interested in rural practice. The Spokane Program in Washington State had implemented a successful rural model, but family medicine resisted replication of this model. Department faculty rose to the challenge of admitting the right students. Departmental leaders negotiated with accrediting bodies for two years before the rural training tracks could begin. The efforts of Dr. Sitorius and Dr. Stageman helped not only rural Nebraskans, their efforts helped open the dam for a flood of rural training tracks across the nation.
The department faced similar resistance when it began the Accelerated Rural Training Program (ARTP) Accelerated Residency Program Track. This is the only accelerated program in the nation dedicated to rural efforts (out of 12 accelerated programs). The American Board of Family Practice placed a moratorium on new accelerated programs soon after the approval of this program, the same situation that existed previously with rural training tracks. Fortunately one opportunity in the right hands was enough. Over 70% of the four ARTP graduating classes have chosen towns of less than 5000, a track record matched by only a handful of programs and none of these are based in an academic department. Because of the success of this program in meeting state and national needs, Family Medicine may have to reconsider this decision. The department has again paved the way for programs that would serve the rural communities in most need. Meeting the Needs of Underserved Rural and Inner City Areas with Accelerated Graduate Training - for more info and tables comparing ARTP and RTT grads
Despite its lofty goals, the ARTP program would have been a dismal failure if it had not delivered the training that it promised to residents. This means procedural and hands-on training. Dr. Stageman faced the daunting task of arranging rotations where residents would do more than just participate. This meant finding the ob-gyn, neonatal, surgical, anesthesia, and critical care physicians to meet the needs of the family practice 4th year rural fellows each year. Finding these physicians to serve in faculty positions is difficult because many of the specialists realize that they might be training their own competition. Others have not been confident with the abilities of family practice residents. Dr. Stageman met this challenge and the ARTP residents have proved their capabilities, in training and in practice. Dr. Stageman continues to serve in an advisory capacity for several rural training programs across the nation.
The Combined Outstate Residency experience The CORE Program is also an example of how the department has gone beyond other departments and programs to meet the needs of rural Nebraskans. Most rural rotations send residents intermittently and electively to rural locations. This provides little help to the rural communities or physicians. The resident spends much time in orientation and adaption and little time in service delivery and learning. The CORE program selects 4 rural sites that are in need of one or more physicians. Sites remain on the CORE program for up to three years. CORE provides a family practice resident throughout the three year period. Each family practice resident goes to one of the rural sites for 2 months. Because the flow of resident FTE is constant, the location can maintain and even build market share for the local rural health system. This is critical to maintaining access and services. Sites losing a rural physician have used CORE to be able to meet overwhelming needs. Only two CORE sites in the past 20 years have not recruited a resident to continue to meet local needs. CORE not only trains residents how to be physicians, it also trains communities how to recruit good practitioners, something that many rural communities have forgotten.
The Department Attracts, Supports, and Develops Leaders for the State and Nation. Dr. Sitorius advises the Chancellor and Governor in rural health matters. Dr. Sitorius has supervised the development of the Rural Health Education Network, a primary means of reaching out to rural Nebraska. RHEN conducts a series of efforts across rural Nebraska, including eighth grade science fairs, training seminars for rural science teachers, career fairs for rural high school students, and workshops for rural students who are in college and want to get admitted to medical school. All of this has been accomplished without federal dollars, as Nebraska has yet to receive any Area Health Education Center funding.
Leadership in rural medical education at the state and national level is not limited to one or two people at the department. The department has recruited and retained specific rural-oriented faculty. Jeff Hill, a former rural physician, rose through department ranks to establish residency clinics and become Dean of Admissions. Dr. Hill selects students for the Rural Health Opportunities Program. Rural Health Opportunities Program This program admits rural high school students into medical school. RHOP students attend Chadron and Wayne State before coming to UNMC for medical school. The program not only gets the right people into the rural pipeline, it also has boosted the academics of these two small colleges. Even more importantly, RHOP allows rural people to stay in small rural colleges for pre-professional training. Students at these schools are far more likely to return to rural communities than other students who have been forced to attend urban colleges that traditionally have a better track record in pre-professional preparation and admission. This efforts of leaders such as Jeff Hill working cooperatively with professors at Chadron and Wayne State have given the state a chance to restore young professionals of all types to rural areas.
Dr. Paul Paulman continues to direct the rural preceptorship effort. At 50 years, this is one of the oldest preceptorships in the nation. Nebraska Rural Family Practice Preceptorship Rated Best Dr. Paulman has moved this program from the 4th year to the 3rd year of medical school, early enough to impact on decisions for primary care and rural practice. All Nebraska third year medical students have been required to spend 2 months in a rural location for years. The department also coordinates the first year rural preceptorship for all medical students. The great success of these programs is largely a function of the rural preceptors and the close relationship between the department and the preceptors.
The department has long recognized the need to have dedicated rural medical educators. Dr. Sitorius recruited Robert Bowman to the department in 1992. Dr. Bowman has led rural medical education efforts for the nation for several years, involving a number of presentations and publications, faculty development sessions, a rural medical education web site, electronic journal efforts, and a list serve. He now serves as Chair of the Rural Medical Educators Group of NRHA. The efforts of this group will likely shape rural medical education efforts in the country for decades. This work is possibly because the department invested well over one million of its own dollars to create and support the position of Director of Rural Health Education and Research. www.ruralmedicaleducation.org
Excellence in the department can be measured in a number of ways. In national evaluations, graduating students note consistently that the rural preceptorships have been the most outstanding feature of their medical training. Nurses, faculty, and others back at residency clinic locations note that residents leave for CORE sites as residents and return as practitioners. The department has been recognized for significant contributions to the state by the University of Nebraska, on several occasions it has finished in the running for the top department in the entire University system. The National Health Service Corps SEARCH program SEARCH in Nebraska administered by department faculty received an award for excellence from the Public Health Service. Dr. Bowman and Dr. Paulman have both been recognized as Public Health Service Primary Care Health Policy Fellows. Despite this recognition, the most significant measurements for the department remain the superior preparation of students and residents for rural practice, the recruitment of residency graduates into rural practice, and the support and retention of these graduates in rural practice. Department faculty and leaders have not been satisfied with average performance and programs. They have established programs that have impacted individuals, institutions, the state, and the nation. This impact will continue for generations.
One of the most important roles of the department is to facilitate exchanges between practitioners, state officials, communities, students, residents, and institutions. In fact, much of the credit for the success of department programs is the direct result of working closely with the rural practitioners and rural hospital administrators in the state. The strength of the department has been in recognizing the potential that has been there all along and taking the training to higher and higher levels while overcoming significant barriers along the way. Faculty, researchers, and coordinators work with practitioners across the state on practice management, technical assistance, preventive medicine, and teaching. The department realizes that its most important function is to continue the flow of high quality physicians to rural areas in the state.
The department provides significant connections between various state organizations and institutions. It works closely with the Office of Rural Health to develop recruitment materials, provide recruitment fairs, deliver technical assistance, facilitate rural conferences, and manage the NHSC SEARCH program. The department works with the Physician Assistant Program, the Assistant Dean of Nursing, the Director of the Family Nurse Practitioner program, pharmacy, and Creighton Medical School to direct the SEARCH program. Family Medicine faculty have assisted the Center for Rural Health Research on managed care, rural network development, and various research projects. Faculty work with the Chancellor’s office on rural programs such as the Rural Health Education Network, the Rural High School Career Fair, and the Student Association for Rural Health. Faculty also work with the Federal Office of Rural Health Policy, the Public Health Service, and several medical organizations in the state. They also work with the American Academy of Family Physicians in several areas and have provided the rural presentations for family practice students and residents interested in rural practice since 1989. This presentation involves medical educators and program directors from several states, rural practitioners, state and federal recruiters, the National Rural Health Association, and offices of rural health in multiple states.
Although the department has faced many barriers, it is determined not to create any. Expertise at the department in rural medical education is shared freely. Department faculty consult with departments and programs and faculty across the nation on a monthly and sometimes a weekly basis, including career support for faculty and fellows, program design, project review, and dealing with barriers to accreditation and implementation. Web materials are distributed free of charge.
The entire department is involved in rural efforts. Family Medicine Departments have academic dedication to service, education, and research. The rural efforts of the UNMC Department are not limited to the graduate division. The department research division sponsored a massive program examining preventive medicine efforts in rural practices throughout the state. While doing so it determined the structure and function of rural practices in over 50 rural sites. Nearly 200 physicians received specific feedback regarding their practice organization and practice habits. Other research efforts might have attracted more funds. A different research focus would have been easier and more financially beneficial to the department, but it would not have served the needs of the state. Other contributions include recruitment fairs, rural visits, health system studies, rural student support programs, and technical assistance to physicians and practices.
The department also delivers direct rural physician services. The CORE component plus an innovative rural moonlighting program for residents and the services of the rural training track residents results in nearly 10 FTE of rural physician services a year provided directly to underserved rural locations in the state. If all of these 10 FTE were combined into one county, it would be the largest rural clinical practice in the state.
Department faculty have published national studies in a number of areas. These include studies of rural faculty, family practice residency programs that graduate rural physicians, rural preceptorships, rural recruitment and retention, and rural training programs. Predoctoral faculty have developed preceptor training materials and initiated national efforts to improve the teaching by rural practitioners. Department faculty who have been promoted to Associate and Full Professor levels have done so largely by their efforts in rural medical education.
The department fields a service-learning program, the National Health Service Corps SEARCH program, sending 30 students a year into rural Nebraska communities. The Nebraska program focused on improvements to rural health delivery through needs assessments, grant applications, and other efforts. All together the research, education and service efforts of the department involve over 60 communities through programs and projects that that serve minority, migrant, Native, and geriatric populations.
This commitment to the needs of the state and nation has challenged the department physically, structurally, and financially. During three years of residency training, family practice residents see patients and produce significant revenues for departments. The loss of resident revenues at the clinic and the sacrifice of faculty lines for rural programs continues to cost the department $1.5 million dollars a year. Rural efforts consume over 25% of the department budget. Rural faculty attend conferences and perform other duties that take them away from seeing patients and generating revenue. The deficit has been made up by departmental faculty who have had to see more patients and assume additional duties. Urban underserved efforts involve an additional $700,000 a year in lost revenues and faculty FTE. Doing the right thing is costly in terms of resources and it takes an entire department to shares in this kind of effort.
It is difficult to convey how challenging it is to resist the temptation to compromise. For instance, it would be easy to combine rural efforts with existing department functions or to convert rural positions back to urban ones. This would save on expenses and improve revenues for internal department uses, but it would not meet the needs of Nebraska. It would be easy to yield to faculty pressures to follow other ventures or ease back on the clinical and teaching demands. Indeed, the increased workload on faculty has strained the department, but the mission remains intact and flourishing. The department has overcome overwhelming barriers at the local, state, and national level. I know of no other program more deserving of the Rural Program of the Year Award than the Department of Family Medicine at the University of Nebraska Medical Center.
Rural Contributions of the Dept of FM