Robert C. Bowman, M.D. Associate Professor
University of Nebraska Family Medicine Director Rural Health Education and Research
Past Co-Chair NRHA Rural Medical Educators Group Chair of STFM Group on Rural Health
http://www.unmc.edu/Community/ruralmeded/rme.htm
Progress in Rural Medical Education 1990 to 2004
“Progress” reviewed since AAMC Rural Medical Education conference in 1990 and progress toward the goals of this conference. We had great plans however .....
Tables of Family Medicine Residency Graduates – comparisons of allopathic, osteopathic, and international medical school students who have graduated from family practice residency training programs in 1997 – 2003. Schools are ranked by rural graduation rates and total numbers given. The new leader in family practice graduation totals is Ross University in Grenada. Ross contributed over 90 of the 2003 FP Graduates. Osteopathic and international schools continue to move allopathic programs out of the top positions regarding FP grads. Regarding rural graduates, osteopathic schools share leadership with Duluth, Mercer, and a handful of allopathic public medical schools. Multiple tables and rankings
Why a Preceptorship Is Better – review of rural preceptorships and studies documenting the value of preceptorship training
Medical Education Retardation - current concerns regarding the preparation of physicians to serve the underserved, rural and urban, given the slow deterioration of medical education intensity and volume and impacts of liability and disruptions of continuity.
Accelerated Family Medicine Training Programs
Changing Rural Background and impact on Medical Education
Family Medicine Physician Distribution - Recent Graduates 1997 - 2003
New Presentations
Rural Background, Rural Interest, Rural Workforce - compilation of old and new studies documenting reasons for RME
Rural Medical Educators and Rural Workforce - challenges in RME and opportunities
Community Driven Approach: Linking Resources with True Needs
Heroes in Medicine – Docs of the year and role models
Admissions Package – for more and better rural physicians
Search on the web site for over 2000 files with 10000 hyperlinks involving rural medical education.
Robert C. Bowman, M.D. rbowman@unmc.edu
We have a real problem with distribution by location (shows that only FP/GP go to smallest areas)
We have a real problem with the loss of primary care. (shows continual decline in percentage of physicians in primary care over the last century, not a pendulum likely to rebound)
We have a real problem with not getting students admitted who are likely to chose rural areas (below shows decline from 27% rural background to 16%, more than population demographics and likely the deterioration of education plus small college issues such as funding, advisement, career orientation as well as rural background students forced to go urban to find good premed).
Rural Background students still taking MCAT, but not getting in
This is not good for the nation, for rural areas, for medicine, for medical education, and for students.
Secret One: Rural Practice is the Best
uUse all your skills and talents
uThe chance to get to know patients best
uWorking with great people
uMaking a difference in a community that needs you
Rural Practice – the Best
uMost challenging problem-solving
uTherefore the most learning, regarding people, the community, diseases – the heart of medical practice
uGreat Role Models – see the video with Bob Boyer, spend time with rural docs
Secret Number 2: Rural docs are the best physicians
uAccept responsibility for full contact problem solving in multiple dimensions
uEnhanced ability to stamp out disease
uBy far the best value
Rural Docs Stamping Out Disease
uColonoscopy + Continuity, scopes in follow up reveal virtual
uElimination of precursors of colon cancer
uValue of continuity
uWorking with schools, community, leaders
Rural FP Docs and the Best – from research by Paul James, Chair of Rural Health Iowa
uAbout Paul
uCardiology vs FP in post MI
uAssumption Heart Docs see sickest, dead wrong
uFP pts more risk, sicker, older, more anterior, worse markers
uyet
James and Care of Hearts
uFP patients not in critical care unit
uNo study shows FP worse
uNo research explains the above,
usimilar to other half-truth studies done in such comparison
uGreat care at much lower cost
Secret 3: Rural Docs = Best Teachers
uNew rural docs going to FP programs to teach quickly get teacher of the year awards
uStudents rate FP rotations in rural areas best at schools across nation
uPaul James study – 8 med schools, no difference in location, tendency toward better education the farther from the med center (sorry, get at least one-half truth from our side)
Secrets Explained
uHealth care system a mess, less a mess in rural areas where patients and docs matter
uContinuity of care a big factor in docs letting students and residents actually “practice” medicine, the whole point of medical education
uLearner works with one or two supervisors over two months rather than a cast if thousands
uSeeing more of the life of a doctor, the real world
uStudents respected in rural communities
Secret 4: Students Interested in Rural Practice Are the Best
uIn it for service, caring, making a difference
uDesire to be leaders
uRealize the need to make own decisions, not let others manipulate or pressure
uSet their own electives, rural, international, life changing
AAMC GQ 1995 Rural Interested Seniors (allopathic)
uOnly 1000 of 16000 interested in towns of <10k
u60% interest in socioeconcomically deprived
uUsual med student less than 10%
Rural Interested = Service Orientation
uTwice as likely volunteer locally
uTwice as likely to do missions and experiences overseas,
uTwice as likely to try military experiences
uAt all years med school
uActually can’t stop them from doing service and learning, don’t try!
Research Ethics
uWhen a study is so effective that it would be unethical to not allow the intervention to be applied to all subjects, the usual is to terminate the study and adopt the treatment
The data is in, we need more rural docs, more rural experiences, more rural interested students, who will serve patients better – period.
Selecting for these is never a waste!
But Wait, there is more….
Economic Impact
uRural docs worth 1 million a year in impact
uMN RPAP invest of 20 million by state, worth 2.2 billion to rural Minnesota
uHospital, nursing home, pharmacy
uJob multiplier plus jobs kept plus opportunity to recruit jobs in towns with rural docs
Sources of Rural FP Docs
u780 rural docs a year from allopathic graduate FP
uDifferences by type of school, gender
uNon-metro broad difference in counties from 5000 in county to 130000
uFP docs locate in county of size Mean of 860000, 16% growth
2002 FP Graduates Choosing Non Metro (from allopathic
programs)
u18% for Private Allopathic
u24.4% Public Allopathic
51% of midwest males
u39.4% Osteopathic 47.1% of males
u12 – 16% International, US origin best
uMales 5 – 12 percentage points higher than females
Opportunities Seen by RME
uMore rural experiences (recruitment, quality med ed)
uLonger rural experiences (training, workforce, orientation)
uMore female role models
uMore partnerships
Must Increase the Numbers of Rural Interested Students
uHealth Profession Advisors
uRural Students
uService oriented students
uRural Student Interest Groups
Rural Community Characteristics Contributing to Success: Advantage Rural
uAwareness of issues +++
uMotivation from within +++
uSmaller geographic area ++++
uAdaptability ++
uSocial cohesion +++
uAbility to discuss, cooperate ++
uIdentifiable leaders +++
uPrior success
Dead Horses From Divine Humor
uDakota Indian tribal wisdom
uWhen riding a dead horse
uBest strategy is to dismount
In our various government programs however, a whole range
of far more advanced strategies is often employed.
Winston Churchill said that Americans could always be
counted on to do the right thing, after they had exhausted all other
possibilities. Here are some of those Dead Horse strategies.
When you find yourself riding a dead horse, and you are not a Dakota,
then you will be tempted to, (choose one or more for years):
uChange riders.
uBuy a stronger whip.
uDo nothing: "This is the way we have always ridden dead horses".
uVisit other countries to see how they ride dead horses.
uPerform a productivity study to see if lighter riders improve the dead horse's performance.
uHire a contractor to ride the dead horse.
uHarness several dead horses
together in an attempt to increase the speed.
uProvide additional funding and/or
training to increase the dead horse's performance.
uRe-classify the dead horse as "living-impaired".
uDeclare that, as the dead horse does not have to be fed, it is less costly, carries lower overheads, and therefore contributes substantially more to the bottom line.
uPromote the dead horse to a supervisory position.
Examples of Making a Difference and Problems with Research and Researchers who do not take this into account
Oncologist presentation last week. Not a great presentation except for cancer docs, but take home for FP (other than Cleveland Clinic has best stuff in nation for multiple myeloma)
uAmyloid heart has 3-4 month survival. Having a dedicated female cardiologist who interacted with patients resulted in a 15 month survival of amyloid (small study) with treatment, but she left
uStudy repeated on larger number with a mix of cardiologists and the patients only lived 5 months, continuity and dedication counts and may impact research
uPatients were getting significant side effects and dropping out of studies, even beneficial ones. Educating patients thoroughly decreases reported side effects. This allows patients to actually benefit from high tech therapies instead of terminating early
Take Home
uGetting patients to do simple things like take ASA to prevent deep vein thrombosis a key to real success in research studies targeted to patient care
uSupportive, involved care a key to medical practice and research
Also yesterday at a conference with psychiatrist noting how there is a group of patients at some research centers that go from study to study. This helps the center and it helps the patients, many who cannot afford meds, but it makes the research a bit more questionable when attempting to apply it to real practice.
FP research networks may have difficult challenges to overcome, but the patient care is real world.
This means that many medical studies are flawed in composition, management, and perspective
uMedical research in the nation becomes questionable in the hands of people that do not prioritize the patient and the doctor-patient relationship.
So Why Don’t Medical Schools Change from riding dead horse of disease, subspecialty, urban focus?
uOther incentives, contracts, promotion
uIgnorance, poor leadership
uLack of FP leaders in medical schools
uLeaders coming from narrow areas of concentration
Why Doctor's Don't Go Where They Are Needed
We must get the right leaders, the ones who can pick the
kids most likely to return to underserved areas, design curricula to boost
education and maturation, and somehow not socialize them urban, subspecialty, or
out of culture in the process.
Medical Schools Choosing the Right Students Admissions Package
uChoose to support rural and underserved communities
uAre working with state and federal government
uAre rare
But…
uIt is a difficult process
uIt must involve efforts in K-12 and college
uEfforts with health advisors and career advisors
Solution
uSelect early, age 11 – 13
uPrepare well enough to do well
uExpect 10 – 25% will make it to professionals and better distribution to underserved
Priority
uEfforts with small colleges like the RHOP program
uEfforts with college advisors who can help encourage the right students
uEfforts by the students
Efforts By Students, the best hope for improved recruitment of the right stuff
uJohn Klein and Prime Program
uOne of 4 different 1 hour sessions
u8-11th grade level
uI made it, you can too
Learning from Longer Established Former Minorities
uMust add the task of bringing up those behind us
uMust do well, often at great personal cost
uMust continue to look for opps to help those like me who face challenges
Special Populations
Only way to truly meet the needs of the most impoverished and isolated and culturally distinct populations is by gathering candidates from such groups, the ones that most want to return and serve.
How Do You Make a Difference?
uPrepare well
uLife changing experiences
uResist the usual tendencies
World of Rural Medical Education
uMore rural docs Facilitating More and Better Rural Docs
uUnderserved section Underserved - Overview and Models
uStudent section Students Interested in Becoming a Rural Physician
uInspiration section to make a difference Topics and Essays
uwww.ruralmedicaleducation.org
Summary of RME
uBest practices
uBest docs The Role of the Rural Community and Practitioner
uBest people to work with
uBest Education Why a Preceptorship Is Better
uBest students Admissions Package
uRestores communities, small colleges, education, leadership Medical Schools and Restoration
Community Driven Approach: The Rural Component
Rural Choices by Medical School Origin
www.ruralmedicaleducation.org