http://www.unmc.edu/Community/ruralmeded/facil/facdev/minifel1.htm
Abstract
Faculty involved in rural medical education face great challenges. They live in academic centers but their hearts are in rural practice. They must work well in both areas to graduate more and better physicians for rural areas. The 1990 – 1992 Minifellowship in Rural Family Medicine at East Tennessee State University assisted rural faculty in the development of their own rural medical education project during four sessions over the course of the year. The program has been influential in the development of leaders, programs, concepts, and research that continue to serve rural health and primary care across the US and in other countries.
Background
The maldistribution of physicians has been a persistent problem for the United States for many decades. In the background a few devoted medical education leaders continue to help students and medical education programs to fulfill their potential. These rural educators succeed in placing physicians in small towns with a coordinated effort that focuses on admission of the medical students most likely to choose rural family practice, followed by specific training (2,3,4,5,6), and supported by departments and governments while in rural practice.
Medical schools and residency programs that have a rural mission, rural leadership, rural experiences, and superior training graduate more rural family physicians [3,6,7,8]. New studies note that medical schools in the US that have a rural medical education person also graduate more family physicians and more rural physicians [5]. Rural leadership development is a key element [7,8]. Since most rural medical educator positions are filled from existing faculty, on the job training is needed.
Rural medical education shares almost every element with primary care and family medicine, but often on a different and broader scale, with fewer resources, and attempted on a part time basis. As such, rural medical education faculty must often extend to do teaching, service, research, evaluation, and program responsibilities. Often publishing such work is a challenge with so much to do in so many areas. The strain between the needs of rural communities and the limited time and resources available is great.
With each passing year the value of community-based education increases, especially with reference to academic training. Academic locations increasingly have more learners packed into locations with fewer patients and an experience that is more and more atypical to the needs of rural family physicians. The contrast between full time academic faculty and full time rural practitioners is dramatic. (Millennium Conference on the Clinical Education of Medical Students).Full time faculty are spending less and less time on teaching [9] and practice medicine only part time. Urban locations are less likely to have procedural training and connections to the community. Academic experiences are less likely to include important areas such as practice management and personal management areas. Students in rural settings see a more complete picture of the life of a physician. Patient continuity can be a major problem for urban areas. Lack of a relationship with patients makes it difficult to match learners to patients and to allow trainees to participate more fully in “hands-on” learning efforts. All of these factors make rural settings more and more attractive. Rural sites have been compared to academic sites in quality of education and have equal or better education. [16,17,18,19,19a]. Why a Preceptorship Is Better . Flexner, Applicants, Maldistribution.
Those attempting to develop medical education in rural settings must be aware of some key differences in culture. Rural locations, practitioners, and towns expect a different approach. Academic urban settings are often more impersonal. Development of sites and arrangements for rural rotations usually require personal visits rather than phone calls or emails. A community-driven or partnership approach is important. This is very important for indigenous populations [13]. Hobbs outlined the value of rural preceptors and rural visits in his excellent editorial on the “Invisible Faculty” [14]. Those hoping to develop rural sites or programs must have or develop the right attitudes and approaches.
Teamwork between academic and community-based resources depends on the interactions between communities, practitioners, faculty, and, perhaps most importantly, coordinators. With active coordination preceptorships are excellent modes of education [15] that are highly valued by students [16] and supported by rural practitioners and communities.
These rural sites are away from the usual faculty development resources. Most schools or programs that are oriented to the needs of the underserved do not have the additional resources to spare on coordinators, faculty, or faculty development experts. Resources are also strained and there is a great need for academic coordinators to understand how to distribute students and residents in a way that avoids undue strain on preceptors and community resources.
The Combined Outstate Rural Experience in Nebraska is an example of a “community-friendly” rural experience that facilitates top-notch education. Grouping 6 second year family medicine residents into a single site for 2 month rotations over a single year allows the site to be able to provide support. Intermittent residents or 12 months of residents over a year means more time spent in orienting the new resident and less help for areas already in need of services. Accreditation requirements that limitation away rotations to 2 months represent the height of poor understanding of “community-friendly” medical education. Longer times provide more workforce benefit to rural communities. The more organized approach is also able to attract financial support from rural hospitals. In such settings the practices can hire and support a nurse to assist the resident with seeing patients, orientation, and identification of procedural training opportunities. Residents allowed 3 or 4 months in rural community-based settings are also likely to have a greater appreciation of true continuity of care.
More advanced rural medical education models such as long term preceptorships are an unrecognized gold standard for medical education [17,18,19]. Specialized rural faculty development offers the opportunity for faculty to address not only the needs of students and residents, but also the needs of practitioners, underserved communities, and the country[20].
One of the most important and most neglected components of faculty development is replication of faculty, leaders, and programs. A great model may be unknown without replication. Innovative efforts go unrecognized if not shared. There are several excellent rural medical education models that remain limited in scope, numbers, and locations. Without dedicated rural medical educators it is likely that maldistribution will remain a serious problem.
Description
Family medicine faculty at East Tennessee State University (ETSU) developed a Title VII Faculty Development Grant that was funded at a rate of $100,000 a year for three years beginning in 1990. This supported a coordinator, a secretary, some faculty time, and travel for the minifellows and consultants. Minifellows gathered 4 times a year at a rural health or family medicine meetings to review the progress of their rural medical education projects. They attended interactive sessions with rural, family practice, and governmental experts. The needs of the minifellows and their projects determined the curricula, speakers, experts, and meeting choices.
The 16 minifellows included 13 current or former rural practitioners with over 100 years of rural practice experience. The minifellows included 5 graduate program directors/developers, 7 full and part time faculty who were developing rural sites, 1 family medicine predoctoral director, and 1 rural family physician research network director.
The first year's class involved 4 local full time faculty. This group was mostly involved in setting up a rural satellite location in Mountain City TN, teaching students and residents. They also assisted with the development of the minifellowship. The 6 second year minifellows hailed from the southeast region of the United States. The final group was national in distribution.
The minifellowship was revised after the first few months. Local duties tended to disrupt the learning sessions for the local minifellows. There was a lack of focus. The solution was to re-orient the program around the current interest area of the faculty member, usually a rural medical education project. Recruitment of new minifellows was also improved as it was easier to find works in progress, both people and programs, and facilitate their efforts.
A key component of the minifellowship was national mailings and newsletters. Information on current efforts of medical educators was distributed. Directors and chairs were asked to identify a rural contact person. At one point the mailing list involved over 2000 in medicine, medical education, and government.
The minifellowship effort also included a survey of rural faculty to develop contacts and to learn about efforts of other rural medical educators. Surveys revealed that 25% or 900 MD and DO faculty at family medicine residency programs and departments had been rural physicians in the past. The surveys noted that faculty involved in rural health had little dedicated time for rural duties. Those responding noted that they were more interested in giving rural faculty development rather than receiving it. The surveys noted that family medicine residents each year were participating in over 3000 months of required rural rotations. The need for rural faculty development was significant in graduate numbers alone.
Most of the projects of the regional and national minifellow groups involved replication of the rural training track residency model. Minifellows made great progress during their year of training, but most of the projects required an additional year or two for completion, since they involved development of new programs or significant interactions with several entities: state government, medical schools, residency programs, and rural sites.
An additional obstacle was the significant costs of consultants. Rarely could the budgeted consultants meet all of the needs of the various minifellows. The solution was to use family practice or rural health conferences as gathering points for the sessions. This allowed contact with more experts, more education, and more networking at much less cost. Another solution was to add one minifellow each year who had experience with the kind of projects selected. This person was invaluable in the interactive sessions, project reviews, and development of the minifellowship curricula. Additional ETSU faculty and 2 rural fellows attended the sessions. In actual process, all of the minifellows together with the director, staff, fellows, and faculty participated as learners, advisors, minifellowship developers, and consultants.
As in other rural programs, a hard-working coordinator who understood underserved practice was essential. Linda Nwosu filled this role admirably, using her excellent US training and experience, coupled with years of experience involved in public health and health education in Nigeria. The ETSU department had also previously supported the minifellowship director in travel that facilitated the development of the program and the recruitment of minifellows.
Another component was the incredible participation of a wide variety of paid and mostly unpaid experts, consultants, and speakers. A partial list includes Tom Ricketts, Tom Rosenthal, Don Pathman, Eva Salber, Jack Verby, Harry Phillips, Harvey Estes, Mac Baird, Robert Maudlin, Wally Swentko, Jeff Stearns, Bruce Behringer, Forrest Lang, and Federal Office of Rural Health (FORHP) Policy staff and advisors.
Finally the nation provided the minifellowship with a wide variety of learning opportunities, such as the Governor's Rural Health Conference in North Carolina, meetings of the Rural Health Advisory Board (FORHP), and national meetings involving rural health and Family Medicine.
Outcomes
Subsequent evaluations revealed that the minifellowship was an important contributor to the success of the minifellows as rural directors or faculty. Several expressed that they felt that they would not have been able to complete their projects without the minifellowship. The program contributed significantly to the development of second and third generation rural training tracks. Minifellows noted that the training assisted them in contacting other rural experts. It also helped them access and develop new sources of material regarding rural medical education.
The program grew in contacts and in reputation over the years. Dozens of additional faculty, directors, policy experts, and coordinators made it a point to attend the minifellowship activities at annual meetings and even more obtained handbooks and materials. Minifellows continued to participate in minifellowship activities in subsequent years. The program accommodated additional attendees at sessions to provide assistance to minifellows, to those developing similar programs, and to attract future minifellows.
Of the 18 faculty that noted interest in becoming a minifellow, two decided that they were too busy working on their projects to take time away to do the minifellowship sessions. These two dropped out prior to the first session. Another family practice faculty attended one session and subsequently decided to return to rural underserved practice. Contrary to the concerns of this minifellow, this was considered a positive outcome of the program. The remaining 15 attended 90% of the sessions.
Of the original four ETSU minifellows that were encouraged to participate, two stayed involved in rural programs and two did not. One continued as a rural site director for many years. As noted above, two minifellows had already established programs and made major contributions during the year as teachers and mentors.
The nine remaining minifellows in the final two years have remained active in underserved practice and rural medical education. Only one had a significant change in location, moving first to a rural research position and then to accept a newly created position as chair of rural health for a state (one of the first in the nation), and then became a family medicine chair. He has also completed a 7 state multi-center evaluation of community-based medical education. Another minifellow graduate recently left a fully developed rural training program to direct rural programs at another school. One rural minifellow came from an urban background in emergency medicine. He finished the program and his rural satellite project and then established a full service primary care center in an urban underserved community. One of the minifellows built a state rural education and research center capturing millions in grants each year. He recently won the Educator of the Year award from the National Rural Health Association. He credits the Minifellowship with much of the success of this Center. One minifellow is an assistant dean. Another minifellow has recently become a state health commissioner.
Perhaps one of the greatest impacts regarding the program involved the director. He has been a chair or co-chair of rural medical educator groups since the minifellowship ended over a decade ago. He continues to develop and disseminate rural research, models, concepts, and advice through rural list serves and a web site at the World of Rural Medical Education web site at www.ruralmedicaleducation.org that has over 16000 contacts a week [20]. The author and former director continues to direct other rural programs and research on family medicine, rural practice, and rural medical education. In essence the director received the most benefit from 3 years of travel, networking, communications, program development, and interactions with the minifellows, rural experts, and various family practice faculty and directors.
The reputation of East Tennessee State University also received a boost from minifellowship efforts. The ETSU medical school is one of the youngest in the nation, yet it has moved into the top 3 in national rankings for rural medicine. ETSU has continued efforts begun during the minifellowship, including the rural director position, the rural fellowship, rural community-based medical education efforts, and the Rural High School Career Fair.
The 10 minifellows that were already established at their locations seemed to be able to apply their training more effectively than the 3 other minifellows at more junior positions. This seems to be a reflection of research findings. This is similar to findings in rural faculty and program surveys. Having more rural faculty at a program did not impact rural graduation rates, but having the program director as the rural contact person for the residency did (Bowman and Penrod). Directors of departments, programs, and predoctoral divisions set the mission, activities, and budgets. In order for rural programming to be influential, rural medical educators must be leaders.
The program did not succeed in one goal of attracting the interest of rural practitioners who taught on a part-time basis. Efforts to connect rural and academic communities through visits and shared resources and students may be a more useful means to connect community-based practitioners to faculty development (hobbs – invisible, Gjerde).
The minifellowship continued in intermittent yearly faculty development workshops at national meetings and through mailings, list serves, and associations. The Society of Family Medicine Group on Rural Health and the National Rural Health Association Rural Medical Educators Group were special efforts involving major contributions from former minifellows. The last minifellowship activity involved a rural medical education workshop prior to a Society of Teachers of Family Medicine meeting.
Compared to more formal 1 and 2 year full time fellowships for only 1 or 2 fellows, the minifellowship impacted more total numbers.
1990-91
1991-92
1992-93
Conclusions
A rural faculty development program can address the needs of a broad range of rural faculty and program directors. Such programs can support and identify successful models and assist in the development and dissemination of important concepts. Some of these concepts include the
The minifellowship program brought awareness that maldistribution has effective and proven solutions. This faculty development need extends to inner city primary care as well. Both share the common ground of "minority status" in resources, education, and emphasis. The major national funding source for family medicine education, Title VII funding, is continually threatened with termination. All recent presidents have removed funding, only to have Congress restore funding. Government agencies call for more specific targeting of Title VII funding to the underserved efforts that have been the top priority of Title VII [29]. Even a brief review of Title VII faculty development efforts reveals only the rare program or faculty member pursuing underserved categories. Another ripe area for exploration is comparison of family medicine residency clinics with community health centers. CHCs are widely recognized as some of the most successful government programs [30,31]. Family medicine efforts in underserved areas often share the same patients and outcomes, but do not share the studies in a way that could benefit family medicine and the underserved populations served. Without such faculty and program development there can only be increasing separation between primary care and underserved practice.
Rural faculty development can bring the best of town and gown, rather than adding to controversies between town and gown. The rewards are worth the effort since in every case, 1 + 1 = much more than 2 [33].
References
1) Cohen JC Why doctors don’t go, Academic Medicine, Presidents Editorial, December 1998
2) 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
3) Rosenblatt, RA, Whitcomb, ME, Cullen, TJ, Lishner, DM, & Hart, LG. (1992). Which medical schools produce rural physicians? JAMA, 268(12), 1559-1565. abstract/summary at http://www.unmc.edu/Community/ruralmeded/model/medsch/wamirdoc.htm
4) Bowman RC Recent Family Practice Graduates accessed at http://www.unmc.edu/Community/ruralmeded/bowman_fp_grad_2004.htm
5) Bowman RRH Editorial rural workforce – recent submission
6) Bowman, RC, & Penrod, JD. (1998). Family practice residency programs and the graduation of rural family physicians. Family Medicine, 30(4), 288-292.
7) Adapted from Rosenblatt RA above, additional regression studies by Bowman RC Rural Graduation Rates of US Medical Schools http://www.unmc.edu/Community/ruralmeded/facil/research/medical_schools_and_rural_gradua.htm
8) Cordes S Come on in the water’s fine, presentation and article from Rural America: A Challenge for Medical Education, San Antonio TX February 1990 Academic Medicine 65 Supplement 3 brief summary at http://www.unmc.edu/Community/ruralmeded/sanantonioRME.htm
9) Millenium Conference on the Clinical Education of Medical Students, April 28 – May 1, 2001 accessed at http://research.caregroup.org/Institute/Events/Summary.asp previously and available at http://www.unmc.edu/Community/ruralmeded/model/medsch/millenium_conference.htm
10) Medical Education Retardation http://www.unmc.edu/Community/ruralmeded/medical_education_retardation.htm
11) Baicker and Chandra, Medicare Spending, The Physician Workforce, And Beneficiaries Quality of Care, Health Affairs April 2004 http://content.healthaffairs.org/cgi/reprint/hlthaff.w4.184v1.pdf
12) Flexner’s Impact on Medical Education http://www.unmc.edu/Community/ruralmeded/flexner.htm
13) Bowman RC Community-Driven Medical Education: The Rural Component Journal of Rural Health http://www.nrharural.org/JRH/JRH19-3/rurh-19-03-214.pdf
14) Hobbs outlined the value of rural preceptors and rural visits in his excellent editorial on the “Invisible Faculty” (Hobbs, Invisible Faculty). http://www.unmc.edu/Community/ruralmeded/facil/research/authors/Hobbs_Invisible.htm
15) Gjerde CL, Levy BT, Xakellis GC Unique Learning Contributions of a Family Medicine Preceptorship, Fam Med 1998; 30(6):410-416 http://www.stfm.org/fmhub/FULLPDF/JUNE98/ERAM1.pdf
16) Paulman P Student Evaluations of the Third Year 2 month Required Rural Preceptorship at the University of Nebraska Medical Center
17) Physician Redistribution link from Verby JE Physician Redistribution: A Worldwide Medical Problem, Family Practice 1985; 2:151-158 http://www.unmc.edu/Community/ruralmeded/facil/research/authors/verby_articles.htm
18) Worley P and Kitto P and rural and remote Can a Preceptorship
19) Bowman RC Why a Preceptorship is Best http://www.unmc.edu/Community/ruralmeded/precept.htm
James P Community Based Medical Education MedEdIQ
20) World of Rural Medical Education at www.ruralmedicaleducation.org.
21) Senf JH, Campos-Outcalt D, Kutob R A systematic analysis of how medical school characteristics relate to graduates’choices of primary care specialties Academic Medicine 72(6):524-533.
22) Skeff KM, Stratos GA, Mygdal WK Clinical teaching improvement past and future for faculty development Family Medicine 1997;29252-257
23) Continuous or pipeline approach to rural medical education http://www.unmc.edu/Community/ruralmeded/facil.htm
24) Objectives for Rural Medical Education (link) http://www.unmc.edu/Community/ruralmeded/object.htm
25) Importance of admissions of students likely to choose rural practice http://www.unmc.edu/Community/ruralmeded/admissions_package.htm
26) The facilitation role of rural faculty http://www.unmc.edu/Community/ruralmeded/facil.htm
27) Rural Medical Education Capacity Building http://www.unmc.edu/Community/ruralmeded/conf/rural_med_ed_capacity.htm
28) Rural student interest groups/rural high school career fairs/working with high school and college career and health advisors http://www.unmc.edu/Community/ruralmeded/prepare.htm
29) CRIB Model of Local Rural Faculty Development: Competence, Rural Living, Involvement, Best of your community http://www.unmc.edu/Community/ruralmeded/model/medsch/involve.htm
30) US General Accounting Office Health professions education: role of Title VII/VIII program in improving access to care is unclear (report no. GAO/HEHS-94-164). Washington, DC: US General Accounting Office, 1994.
31) Government agencies and CHC Office of Management and Budget CHCs in top ten most successful federal programs 2002
32) Institute of Medicine Fostering Rapid Advances in Health Care: Learning from System Demonstrations. National Academy of Sciences Press, November 2002 General Accounting Office. Health Care: Approaches to Address Racial and Ethnic Disparities. GAO-03-862R. July 8, 2003
33) Shin P, Jones K, and Rosenbaum S. Reducing Racial and Ethnic Health Disparities: Estimating the Impact of High Health Center Penetration in Low-Income Communities. The George Washington University, September 2003 (prepared for the National Association of Community Health Centers).
34) Even a brief review of recent faculty The rewards are worth the effort since in every case, 1 + 1 = much more than 2 (pathman).
35) Accelerated Family Medicine Residencies http://www.unmc.edu/Community/ruralmeded/accelerated_family_medicine.htm
36) Rationale for an Integrated Approach by Carlton and Weston in Academic Medicine (2000) 75:721-723 http://www.academicmedicine.org/cgi/content/full/75/7/721
1. Continuous or pipeline approach to rural medical education
2. Objectives for Rural Medical Education [24]
3. Importance of admissions of students likely to choose rural practice [2] Admissions Package link
4. Need for support for faculty involved in underserved efforts
5. Impact of rural mission and rural faculty regarding graduation of more physicians for underserved areas [3,4,5,6]
6. The facilitation role of rural faculty facil link[26]
7. Rural Medical Education Capacity Building capacity link [27]
8. Value of preceptorships and community-based medical education [19]
9. Rural student interest groups/rural high school career fairs/working with high school and college career and health advisors prepare link [28].
10. Development of the CRIB approach (CRIB link) for local faculty development efforts [29]
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Application to Canada and other nations · Support for gathering rural faculty together to train and influence future leaders for family medicine, medical schools, and government · Better collection of ideas, current models, research findings · Planning for meetings, legislation, support · Support for new program development |
PROGRAM ANNOUNCEMENT
The Minifellowship in Rural Family Medicine is now beginning its fourth year. Its mission is to assist family practice faculty and program directors who are involved in rural medical education.
Schedule: The introductory session of the Minifellowship will be held in three different locations. Prospective candidates should make plans to attend selected Family Practice or Rural Conferences such as RAP, the Family Practice Program Directors June meeting or the NRHA or STFM Annual Meetings in April or May. A special introductory session can be set up by request (to be held in Omaha). Minifellows will attend one of these introductory session, then a three day session in Omaha, and then a final session next year at a rural health or family practice conference.
Curriculum: Rural minifellows will develop a rural health education program involving medical students or residents such as a preceptorship, a rural training track, or a rural health center. Minifellows review and discuss relevant rural medical education literature and programs. Minifellows will attend discussions by experienced rural faculty. Faculty for the minifellowship will assist the minifellows with career and project development.
Track record: Past minifellows and their projects include Joe Florence and the Hazard KY Rural Training Track, Joe Ferguson and the Rural Training Tracks at the North Colorado FP program, Whit Oliver and the rural rotations at Tallahassee FL, Jim Buechler and the rural training track at Terre Haute, IN, Barb Doty and the residency program in Anchorage Alaska, Tom McWilliams and the rural sites at Kirksville College of Osteopathic Medicine, Judy Monroe and the rural training site for the State of Indiana. Paul James at Buffalo, Jeff Warren at Memphis and Mark Penn at Akron Ohio have attended and developed rural sites and/or curricula.
Significance: The minifellowship is the only faculty development program focused on giving vital information, support, networking, and encouragement to faculty who are developing rural programs. Health care reform may impact on primary care, but this is no guarantee that primary care physicians will train or retrain for rural locations. The development of rural faculty and rural programs is an important component of preparing physicians for rural practice.
Logistics: Minifellows need the support of their program director or chairman. They will need transportation, registration, and lodging for the above locations. Materials, coordination, and consultation are provided.
To Apply to the updated version: Contact Bob Bowman at (402)-559-8873 day, rcbowman@atsu.edu
The first year
THE FIRST MINIFELLOWSHIP SESSION at the Governor's Conference on Rural Health in North Carolina gave the ETSU-based minifellows a chance to escape beepers and interact with a significant group of rural health experts. Sessions on reimbursement, rural hospitals, rural community development, AHEC, and COPC highlighted the conference. Special sessions with Harvey Estes and Eva Salber gave minifellows (and faculty) a chance to relieve the exceptional experiences and careers of two pioneer rural academicians.
THE SECOND MINIFELLOWSHIP also invaded North Carolina to visit Greenville for the STFM Regional conference at East Carolina University's Department of Family Medicine. This conference also hosted the Public Health Service Advocacy Program, giving the entire conference a rural flavor. Rural topics included agrimedicine, rural medical education, and rural sites developed by students. Robert Walker from Marshall University and Don Weaver, Director of the National Health Service Corps, addressed the minifellows in special sessions.
THE NEXT SESSION found the minifellows in Washington DC at the National Advisory Board meeting of the Office of Rural Health Policy. Highlights of these sessions included presentations on Medicaid, Rural Health Clinics, and financing of graduate medical education. Minifellows also visited their senators and representatives and health policy experts. Minifellows also attended the legislative action sessions of the National Rural Health Assoc.
SESSIONS IN JOHNSON CITY examined the role of the hospital in rural health, rural medical education, the current rural research efforts at ETSU and new directions for the rural programs. Part of this latter session included nursing and allied health faculty. This gave all the rural faculty in all 3 health divisions at ETSU a chance to interact and network.
A FINAL SESSION held at the National Rural Health Association Meeting in May in Seattle examined a number of topics. Rural hospitals, management, leadership, rural economies, rural sociology, Rural Health Clinics, and more. Special sessions were scheduled with leaders in rural health.
MINIFELLOW PROJECTS for this year include developing the Mountain City site and curriculum, a project to examine the role of physician relationships in rural hospital closure, and defining the rural faculty member.
EVALUATIONS The first minifellowship year revealed that the program accomplished its objectives of training the rural faculty for future programs. Improvements in the rural rotations were noted and the rotations became mandatory. Minifellows were recruited at several of the sessions. The minifellow sessions away from the Tri-Cities seemed to be more beneficial as duties were less of a problem. New faculty received much support.
PROBLEMS NOTED This was the first year of a one-of-a-kind program. The definitions of rural, minifellow, family practice, primary care, and rural curriculum were a key focus and will continue to be. The use of minifellows in their first year was a problem as these faculty were learning the system. Two of the faculty were involved in residency programs without a rural project. Two other faculty were developing a site, but the controversy and other problems at this site disrupted site development, although it was educational.
LESSONS LEARNED Future minifellows must be experienced faculty with a rural project and rural health career emphasis. The project can be early or fairly established, in fact a mix of various projects would be desirable. The goal of using part-time faculty was not recognized. Even the minimal time commitment did not allow for part-time faculty participation. The role of part timers was to provide the rural experience if the full time faculty did not have rural experience. As it was, the rural experience came from minifellows who were faculty with rural experience. This would not preclude a devoted part time teacher but in all likelihood, the participation of part time faculty minifellows would be intermittent without some formal agreements. One or two day workshops every six months or on-site visits may be better ways to teach part-time faculty.
Summary of the 1991-92 Minifellowship
as of September 1991
The minifellowship needs for the 1991-92 session were minifellow recruits with rural projects and rural career emphasis, more rural curricular structure, and more use of consultants. Eight candidates applied and six with residency focus were chosen. More structure was added by emphasizing the projects and rural curricula development with the projects. The developers understood much more about rural curriculum this year. Consultants were added for the first and subsequent sessions and they were given more time to prepare for the sessions. The minifellowship was much farther along than this time last year.
The 1991-92 session began with Rural Medical Education in Johnson City in August. This session focused on rural medical education models, financing of medical education, and rural curricula. Tom Rosenthal of SUNY in Buffalo and Bruce Behringer were consultants for this session. Minifellows presented their projects and received individual and group consultation at sessions at the Sheraton Plaza:
Joe Ferguson attended for Marc Ringel who was preparing four site applications (for Greeley, CO) for two rural and two urban training sites. Evaluation and faculty development were noted to be key areas of need. Joe contributed a sense of vision and commitment, and the experience of a program director.
Joe Florence presented his design for a rural residency in Hazard, KY that will begin on July 1, 1992. His needs were faculty, residents, policies, and job descriptions. Joe contribute to the overall rurality of the program. He added a great degree of cultural sensitivity. He also helped to keep the sessions focused on practical needs.
Paul James is improving rural rotations and developing a central rural focus for his department. His needs involved examination of faculty and personal commitment, leadership, management, and negotiation skills. One of the other minifellows gave him a copy of "Getting to Yes" regarding negotiation skills, illustrating the importance of networking and use of current minifellows as faculty. Paul has a talent for questioning and made sure that what was presented was clear and relevant. He received much support for his rural efforts while in Johnson City.
Whit Oliver is expanding the rural rotations in the rural areas around Tallahassee, Florida. He hopes to eventually develop a rural training track based on outreach and other grants. He needs faculty support, information to develop a rationale for rural programs, and a means of integrating the rural programs with the various interests of a diverse faculty. He will eventually need funding support from several sources. He received information, advice on faculty integration, and support from the other minifellows.
Jeff Warren is developing a rural site and working toward a Certificate of Added Qualification (1 year fellowship) in rural emergency medicine. His needs were learning rural, procedural, leadership, and management issues. He contributed many questions, assistance with departmental support issues, and helped other minifellows with their needs.
Alex Augoustides attended in his role as a fellow.
THE SESSIONS OVERVIEWED rural health policy and rural medical education programs. Tom Rosenthal added his expertise at state legislative issues (he is a line item on the NY budget) and rural program development (at least 4 sites). Bruce Behringer added regional and national perspective about Community Health Centers and the National Health Service Corps. Rubye Beck described needs assessments and community evaluations. Dan Brown from communications discussed the use of videotapes. He reviewed the WCYB tape, the Nebraska Coming to the Country Tape and assisted in planning for future educational uses of these and other tapes. His presentation was exceptional, utilizing the resources in the room, the videotapes, and group discussion. Bruce Bennard added his expertise in curriculum development. Bruce attended most of the sessions. Mike Floyd talked about rural Balint and assisted with the support of several minifellows.
The accommodations were great, the breakfasts were slow, and the assistance of the staff in preparation of many handouts and packets was superb.
Second Session - The minifellows traveled to Chicago for the AMA Conference on Rural Health. The minifellows received instructions on impacting on meetings and hearings and utilized this conference to practice testifying and preparing handouts and statements. The conference covered most of the Ambulatory Issues in rural health from reimbursement to rural modes of practice to other practitioner issues to organization leadership and the building of coalitions. The conferees agreed on the need to work on medical education from without (funding and health policy) as well as from within (rural programs and curricula). National leaders in rural health were speakers.
Minifellows attended special sessions with Kevin Fickenscher (former NRHA president, rural researcher, established Rural Caucus in Congress), Wayne Myers (Center for Rural Health at KY and WAMI Developer), Harvey Estes (Chairman of Family and Community Medicine at Duke and developer of community oriented programs), Bob Maudlin (developer of Rural Training Track at Spokane), and Mike Sitorious (Chairman of Family Medicine at Nebraska). The focus was organizing programs, leading elements of change, developing support from various sources, current program models, future leadership needs, and many opportunities for individual help for minifellows and their programs.
In addition three potential minifellows were added. Mike Sitorious plans to attend future sessions and plans to send faculty next year. Judy Monroe and Roy Bontrager also attended the minifellow sessions. Their interests are in the predoctoral area. Dr. Bowman had an opportunity to network with rural program directors in Nebraska, Kansas, and Illinois.
Minifellows, special guests, and faculty prepared for special rural focus sessions at the RAP Conference in Kansas City and the STFM Annual in St. Louis. Planning continued for next years minifellowship with the first session set for the AAFP Student Resident Meeting in Kansas City, a group presentation of the basics of rural curricula, as well as a proposal for a national program for rural faculty development (submitted to NRHA to Ted Kennedy's health advisor).
The November session returns to Johnson City for a discussion of Rural Curriculum, Evaluation, Hospitals, and Economies.
The next session moves to Kansas City for the RAP conference and presentation of a special rural track to current and developing programs. It is also a chance to recruit minifellows and emphasize rural faculty development as a priority.
The final session in Washington DC at the National Rural Health Association in May will fill out the schedule.
Applications for the 1992-93 sessions can be obtained from Linda Nwosu, Rural Programs Coordinator, ETSU Department of Family Medicine Box 21,130 A Johnson City, TN 37614, or call 615-929-6396 or 615-929-7803 (after hours).
The enclosed material about the ETSU Minifellowship in Rural Medicine describes a model rural faculty development program. It is the only rural faculty development program in the nation. There are several essential elements of the program:
I. Understanding of rural health
II. Assistance in the development of rural curricula
III. Assistance in the development of rural programs and sites
IV. Leadership and management skills
V. Development of rural teaching and precepting skills
VI. Support systems for rural practice
VII. Networking between rural faculty in different programs or states
Rural faculty must know rural health on the local, state, and national level. They must understand rural health policy, reimbursement, modes of practice, rural facilities, and rural economies.
Rural faculty must be able to take rural doctors and communities and build rural experiences that will influence students to choose rural practice. Minifellows are chosen on the basis of their rural projects and programs. Learning is vastly improved if it involves the learner. It is better yet if the material is quickly and easily applied to what the learner is doing. A major focus of the minifellowship is consultation, discussion, and didactics connected with the development of the rural sites or programs.
Rural faculty must know how to work within institutions and legislatures to effect change. They must manage their own time effectively, especially if they want to span the range from practice to teaching to research or administration.
Rural faculty must know how to illustrate the rural difference. The goal of any faculty development program is to prepare students and residents for rural practice. This preparation involves clinical techniques, behavioral training, and recognition of the effect of culture or community on health.
Rural practitioners must also develop a means of support from peers, neighbors, consultants, family or others to continue to meet the needs of patients, family, and community. Through their efforts, rural faculty can support current and future rural practitioners, reduce their isolation, improve their practice management, and improve the quality of their care.
Networking is important to the improvement of current rural programs, the adaptation of current ones, and the development of new ones. Minifellows interact with the fathers of rural programs and rural medical education. They learn the tough aspects of negotiation and curriculum change. They get a boost up on their mentors shoulders so that they can reach ahead and improve the future of rural health.
Application to Canada
Research in Rural Medical Education