Community-Driven Medical Education: The Rural ComponentRobert C. Bowman, M.D. and Byron J. Crouse, M.D.
Co-Chairs of the Rural Medical Educator Group of the National Rural Health Association
Dedicated to Dr. Susan LaFleche Picotte and there is likely no finer example of the Community-Driven Approach than her own.
The words "Country Doctor" call up memories of horse and buggy, black bag, and devoted, tireless servants. These physicians have long earned the respect and admiration of a grateful nation. What is almost forgotten is that rural physicians once commanded the same respect from contemporary medical school deans and experts in medical education, such as Sir William Osler. Osler had a different view than Flexner in some areas, but both tended to support rural needs. Flexner
In more recent times academic faculty are often less respectful of their colleagues in rural practice. Living in an environment oriented toward urban and subspecialty medical careers, students rarely question such attitudes. By the senior year of medical school, only 362 students out of 16,000 allopathic senior medical students remain interested in practicing in towns of less than 10,000 people. Rural Interested Senior Medical Students 1995
Medical education leaders face regular and appropriate criticism for failure to graduate physicians who will locate in underserved areas. Most ignore the concerns. A few deflect the blame by citing the poor rural economy and "a paucity of satisfying cultural and civic outlets" to attract graduates (Cohen, Why Doctor's Don't Go Where They Are Needed, 1998) . For such highly educated and respected people with enlightened attitudes toward tolerance and understanding, this is difficult to comprehend. The only plausible explanation for such a frame of reference is lack of contact with rural communities and peoples. For the richness of such interactions see The Invisible Faculty by Joseph Hobbs, M.D. . In more recent years, some of the same medical leaders have seen the need to admit students for more than just intellectual criteria.2 As noted by Madison, 3 "If an admission committee informs itself of what finally happens to those it admits, its decisions can contribute to achieving whatever policy its medical school adopts with respect to the mix of physicians it wishes to produce." Service Orientation
Medical leaders have far to go to understand that medical education still has the power to transform college and high school education in America. The Flexnerian reforms that resulted in raising the standard of physician training also resulted in the closure of many of the sources of rural and underserved physicians for the nation. Nevertheless, a few medical schools have rediscovered their ability to transform education in rural areas by working with communities and small colleges, thus restoring the primary sources of young professionals for small towns.
There are various levels that characterize academic institutions’relationships with underserved communities. Assessing Community OrientationSome ignore them. Others take a community-responsive approach where they respond when pressured or when such activities meet their needs. Others have gone further by implementing a community-driven approach. When applying the community driven approach to medical education, the needs of underserved communities must drive the pre-professional preparation of students, the admissions process, the academic environment, the training curricula, and the practice environment of graduates.
The recruitment of a physician to a small town is best described as a courtship process. As such, the community-driven approach is a marriage where each entity, underserved or academic, is willing to sacrifice for the other. These marriages of rural and academic communities have created some excellent medical education models that hold the potential to graduate more rural physicians.
The community-driven approach is best illustrated by existing models. Among them is Jefferson Medical College’s Physician Shortage Area Program (PSAP), which began with a special medical student admissions track in 1971. The community driven aspects include the selection of students from rural areas who have interest in a career in family medicine. These two student factors are the best predictors of eventual rural practice location. PSAP also involves small college health professions advisors who play a key role in the selection of the PSAP students at Jefferson. Rural communities have reaped the rewards of the program. While PSAP involves only 1% of all of the medical students in the entire state of Pennsylvania, PSAP graduates now constitute 21% of the state's rural family physicians.
Another example is the Rural Physician Associate Program (RPAP), which since 1971 has involved 40 third-year University of Minnesota medical students each year. Half of the students selected are from the university’s traditional Medical School and half from its School of Medicine-Duluth 2-year program, where medical educators put a priority on selecting and preparing rural and primary care physicians.5
The RPAP program gives just a hint of the economic impact of restoring young professionals to rural areas. RPAP has graduated over 900 physicians, with over 260 graduates locating in rural Minnesota. Using figures from the Oklahoma Physician Manpower Training Commission, each physician is worth $954,000 in local economic activity. Minnesota’s investment of $800,000 a year since 1971 has resulted in an estimated $2 billion in economic activity in rural Minnesota alone.
The Nebraska Rural Health Opportunities Program (RHOP) is yet another example of the community-driven approach. After a series of meetings with rural communities and small colleges, the University of Nebraska Medical Center decided to create special rural admissions tracks for a number of health professions. The medical school decided to admit 10 students a year to medical school after preparation at Chadron State College or Wayne State College.
RHOP increases the diversity of those admitted by working with small colleges as recommended by Wheat. The main drawback noted by Wheat was the doubling of the failure rate from 5.3% to 10.6%.7 The first groups of RHOP students faced academic, social, and political challenges, but the community driven design took care of these. The selection of only one or two colleges to work with RHOP at either end of the state attracted a larger share of the academically-gifted rural high school students. The natural competitiveness of such students has raised academics at the two colleges and eliminated the gap between RHOP and traditional students regarding preparation. Increasing numbers of Chadron State and Wayne State students not involved in RHOP have been admitted to professional school.
The RHOP program also has some of the retention potential of the PSAP program in Pennsylvania. High school students in Nebraska have the option of choosing a rural location for higher education rather than being forced to an urban college just to improve their chances for admission into professional school. At a small college they are also more likely to meet and marry a spouse who would be more likely to return with them to a small town. Those making that important first choice of a rural location for higher education, may be more likely to choose rural locations for practice. They may also stay in rural practice longer.
The increased number of rural-interested students has allowed the University of Nebraska’s Family Medicine Department to develop a variety of rural training track programs and a new accelerated rural training program model. Graduates of the department’s residencies have entered rural practice in the state at a rate 50% higher than a decade earlier (60% vs 40%). Contributions of the UNMC Department of Family Medicine
Perhaps one of the strongest community-driven models is the Minnesota Rural Health School (MRHS). This interdisciplinary education program represents a partnership between multiple academic institutions and rural communities with shortages of health professionals. MRHS involves students in medicine, pharmacy, nursing, physician assistants and social work. The academic programs identify curricular goals in conjunction with communities, and communities identify opportunities to meet these educational goals. Service-learning is a key component, providing services to the community while enabling students to develop skills to function effectively in an interdisciplinary health care team. Outcomes include increased interest in rural practice and the team approach to care. MRHS students have developed an increased understanding and appreciation of the work of other health professionals. Of those who have finished their education, 67% are practicing in rural communities.
In Arkansas a comprehensive pathway was developed more than 20 years ago involving Area Health Education Centers (AHEC), admissions strategies, decentralization of graduate medical education (especially family medicine), and outreach to rural communities. The state experienced a 20% increase in the physician-population ratio in a 5 year period when other states in the south and midwest gained only 10%. The above are just some examples of states that have added workforce where it is most needed with a coordinated approach integrating dispersed medical education at a number of levels in education and training.
Deans, AHECs, rural faculty, admissions committees, and underserved communities can initiate such approaches, even without special state or federal funding. It is significant that a medical leader such as William T. Butler, chairman of AAMC in 1991, has noted these same successful rural models. Academic Medicine's Season of Accountability and Social Responsibility Dr. Butler also noted a model at Baylor College of Medicine that integrates medical education and underserved people beginning in high school. He emphasized the need to meet local and regional needs. Unfortunately few have listened to him and the crisis in rural health and academic accountability has grown.
The “Community-Driven Approach” empowers underserved communities so that they can guide the efforts that will best address their needs. This approach has great potential to permanently improve small towns in terms of jobs, leadership and services without extensive state or federal support programs. The Community-Driven approach: a) arises from mutual efforts involving both academic and rural communities; b) selects students from underserved areas; c) trains learners in underserved communities; d) stabilizes and supports underserved practices; e) prepares future generations of physicians for underserved practices; and f) allows towns to preserve and expand health services, a key factor in keeping current jobs and recruiting new jobs and businesses to small towns.
The community-driven approach is not as complex as it seems. The beauty in this approach is that it restores proper relationships, incentives and emphasis. Successful rural health systems have already discovered many of these principles. They know that the answer for higher quality rural health care is improved working relationships between boards, administrators, physicians, nurses, patients, and community members. Academic health centers need to learn the same lessons by working more closely with rural and underserved communities to continue serving the nation effectively far into the 21st century.
Changes in medical education during the past century have increasingly been driven by funding sources, particularly research grants and graduate medical education. Medical schools have ignored community needs more and more with each passing year. Despite this trend, within most medical schools there are those who attempt to address the needs of the underserved. Unfortunately faculty, student and support staff efforts often go unnoticed.
We propose establishment of a specific recognition program for those individuals and medical schools who are addressing the needs of the underserved. Devoted individuals would have a better chance of attaining leadership positions. A coordinated effort would help graduate more young professionals for underserved areas.
We suggest naming such a recognition program in honor of Susan LaFlesche Picotte, M.D., (1865-1915), the first female Native American medical doctor and among the best examples of those physicians who rise from underserved communities to return and serve their people. Her heritage included 3 native tribes. Her father was the last of the Great Chiefs of the Omaha tribe. Her grandfather was the first military physician in the state of Nebraska. She found support for education and excellence from her parents, those in the tribe, and advisors in small colleges. She graduated at the top of her medical school class at Women's College of Pennsylvania in only 2 years. She returned to the reservation, serving her own Omaha tribe as well as other Natives and white people, all hours of the day and night and in all parts of Thurston County, NE. She continued her work despite chronic ear problems for most of her life. She battled tribal plagues of alcoholism and tuberculosis, and governmental plagues of ignorance and bureaucracy. She raised the money for the first reservation hospital not built by government funds. She helped establish the Thurston County Medical Society and traveled in the US and Europe to bring attention to the needs of native peoples. If medical education graduated even a few each year from each class that were somewhat like her, the plight of the underserved would be much improved.Susan LaFlesche Picotte
1) Cohen, J. J. President's Address: why doctors don't always go where they're needed." Acad Med 1998;73:1277.
2) Cohen, J. J. President's Address facing the future. Available at http://www.aamc.org/newsroom/pressrel/2001/011104a.htm, Accessed April 1, 2003.
3) Madison, D. L. Medical school admission and generalist physicians: a study of the class of 1985, Acad Med 1994; 69:825-831.
4) Rabinowitz HK, Diamond JJ, Markham FW, Paynter NP, Critical factors for designing programs to increase the supply and retention of rural primary care physicians, JAMA 2001;286: 1041-1048.
5) Verby, J. E. Changing the medical school curriculum to improve patient access to primary care. JAMA 1991;266:110-113.
6) Oklahoma Physician Manpower Training Commission. 25 + Years: Oklahoma Physician Manpower Training Commission. Tulsa, OK: Center for Health Policy Research, Center for Health Sciences: 1998.
7) Wheat JR, Brandon JE, Carter LR, Leeper JD, Jackson JR. Premedical Education: The Contribution of Small Local Colleges. Journal of Rural Health, 2003;19:181-189.
8) Stageman JH, Bowman RC, Harrison JD. An Accelerated Rural Training Program, Journal of the American Board of Family Practice, 2003;16:124-30.
9) Crouse, B. J., Block, D., Elliott, B., Larson, T., Ludwig, D., & Swentko, W. Minnesota’s new rural health school. Minnesota Medicine 1998;81(6):27-31.
10) Crouse, B. J., Mueller, C., Uden, D. AHC – community partnerships for interdisciplinary education. Academic Medicine 1998;73(9):920-921.
11) Bruce, T. A. & Norton, W. R. Improving Rural Health: Initiatives of an Academic Medical Center. Little Rock: Rose; 1984.
12) Butler, W. T. Academic Medicine's Season of Accountability and Social Responsibility, Acad Med 1992;67:68-73.
National Library of Medicine, Exhibition, If you knew the conditions… Health Care to Native Americans, http://www.nlm.nih.gov/exhibition/if_you_knew/if_you_knew_12.html Accessed February 5, 2003.
The Nebraska RHOP Rural Health Opportunities Program
Meeting the Needs of Underserved Rural and Inner City Areas with Accelerated Graduate Training
The Minnesota Rural Health School (MRHS) http://penguin.d.umn.edu/rhs/rhs.html
When noting successful rural models in his address to AAMC, Dr. Butler also noted a model at Baylor College of Medicine that integrates medical education and underserved people beginning in high school (Butler Address to AAMC 1991). http://www.tmc.edu/institutions/hshp.html Others at institutions such as Montefiore in New York have dedicated their efforts in this area. http://www.aecom.yu.edu/family/dfmrpsmfamprac.htm
Organizing Rural Medical Education
Rural physician-educators and rural academic faculty play a key role in facilitating the careers of individual students and residents. Personal contact is also the major mode of replication of rural medical education. Jack Verby's sabbatical to Syracuse resulted in the first replication of RPAP. Robert Maudlin's interaction with faculty and program directors spread the rural training track model. The Minifellows in the rural faculty development program at East Tennessee supported one another in the development of programs, strategies, and research. The Minnesota RPAP preceptors pass their knowledge and experiences along to successive generations of students who become physician-educators. The Rural Medical Educators Group of the National Rural Health Association (NRHA) continues in this tradition with annual meetings, an active list serve, web sites, publications, and efforts to improve rural medical education at all levels. For the latest in information on the National Association of Rural Medical Educators
The Community-Driven Approach empowers underserved communities so that they can guide the efforts that will best address their needs. This approach has great potential to permanently improve small towns in a number of areas such as jobs, leadership, and services without extensive state or federal support programs. The Community-Driven approach
Flexner and AAMC did not know that reforms would result in chronic physician shortage situations. States did not know that changes in state expenditures to provide for underserved people (elderly, Medicaid) would result in budgetary problems that would result in a centralization of education that would then destroy the small college breeding grounds of young professionals for rural areas. Legislators did not know that restrictive laws, federal and state audits, inconsistent support of primary care training, a crushing liability climate, and programs to reduce medical costs would produce unintended consequences that are significant barriers to rural health care. The nation also does not need to depend on expensive programs to send rookie physicians (from this nation or stolen from others) to underserved areas for only a short span of time.
Obligations vs Grow Your Own
Objectives for Rural Programs and Curricula