Duluth Plus RPAP

The Duluth 2 year Medical School  http://www.meded.umn.edu/    Jim Boulger

Duluth is a 2 year medical school with a mission to graduate more rural family physicians. No other school has attempted this mission so well and accomplished so much. Duluth consistently has the highest "match" in FP at 50% of graduates, since creation. It also has over 30% of FP docs going rural, with other graduates going rural as well. Admissions is the key.

Duluth 20 Questions for admission - what helps focus on the best FP choice and distribution

Family Medicine Standards and Constants - Top Workforce Outcomes Rankings - Duluth a leader

The Minnesota Rural Physician Associate Program

Internet Address for RPAP    

Verby Articles on RPAP and rural medical education   Jack Verby

RPAP is 9 months in the third year of medical school in a small town with a rural FP doc. There is no better rural, correct that. There is no better MEDICAL education model in the nation. Medical school greatly limits what the attending physician knows about a student and what the student knows about the attending, his or her practice, and patient care. RPAP allows students to progress much faster with learning since it is a real world setting without competition. The value of a rural FP doc is the continuity base (knowing patients) and the breadth of knowledge. This is a much better fit than a teacher with little continuity and depth in a certain area of medicine. 

RPAP is a good example for those who would plan and implement effective rural interventions. The program involves multiple levels, it coordinates primary care training in a more pure form, and it impacts the spouse. RPAP resulted from the frustrations of a state senator who wanted more rural physicians. The state forced change on the institution and, to its credit (or debit), the state funded the program with $800,000 each year.

Even with good funding, the program faced critics at the institution as well as outside. RPAP survived and demonstrated quality education. It also boosted rural physician production in the state. RPAP alone should not receive all the credit. The Duluth program acts as a feeder to RPAP to admit rural-oriented candidates and support them in their rural decision over the first two years. Half of the RPAPís 40 students a year come from Duluth.

RPAP is rural training and it may influence some students to choose the smaller locations. RPAP students also have to take spouses with them on location. Critics of RPAP point to Duluth selections as the real reason and note that evaluation of the program is flawed by selection bias. In any case, RPAP has distributed rural physicians throughout the state, it has supported current rural physicians, educated physicians well, kept them in rural practice longer than the national average, and located 60 physicians back to the site of their original RPAP training. RPAP graduates in rural Minnesota know that they are training their colleagues and replacements.

Longer rural experiences give students an opportunity to learn much more than biomedical information. Minnesota's Rural Physician Associate Program is the premier program here. Its success is measured in the 58% of students who practice in rural locations (national average is 6%), the 341 out of 545 who entered family practice (1991 Match at 10%) the demand for the clinical preparedness of the RPAP students by family practice residencies, the spawning of at least three other RPAP like programs, and equal or higher scores for RPAP students in clinical skills (26/29), behavioral skills (4/18), and professional skills (3/7).

RPAP students spend 9 months of their third year (first clinical year) in a rural area with a rural preceptor who most likely is a former RPAP student. RPAP students and their spouses move to the rural area. They start by observing their preceptors and meeting the other health providers in the community. They see patients, read, and work with faculty from the medical school on videotaped encounters, medical interviewing, and clinical information. Specialists work with the students at their home sites. Computers connect the students with information databases and the home medical school.

RPAP students know their career options, referral resources, and the issues regarding balancing careers and families much better than non-RPAP students.

The faculty development training of the RPAP program starts with the student. Preceptor and student alike know that there is a high degree of likelihood that the student will be an RPAP teacher. As the student learns medicine, he or she learns to teach. They receive 75 different lessons on medical interviewing alone. The one on one interaction of the student with the rural preceptor (30 contact hours a week) is emulated by the one on one student to faculty training on site. Faculty become teaching role models. RPAP trains its rural faculty regularly at workshops on and off site.

RPAP is financed by the state and the local physicians. Students receive a $9000 nontaxable stipend for the first six months and $3000 from the preceptor for the last 3 months. Verby noted that RPAP students generate an extra $40,000 to $70,000 in billings for the rural practice as compared to years when there is not an RPAP student present.

RPAP works because it develops a rural background in the student and spouse, it is continuous, it is involved enough to form a community bond, and it meets the special needs of preparation for rural and primary care.

RPAP resulted from rural physicians, legislators, organizations, and the medical school working together from 1971 until the present. In Verby's recent article in JAMA, he stated that "Strong leadership will be needed from within medical schools and from other interest groups to bring about future growth in the primary care specialties". Faculty development also involves learning about leadership and meeting rural, family practice, and primary care leaders.

Overview from MN Center http://www.ruralcenter.org/pdf/oncenterv3no2.pdf

Urban RPAP  http://www.metrodoctors.com/Publications/00_05.pdf

REALIZING THE POTENTIAL OF PRECEPTORSHIPS When used as the major method of educating students in their clinical years, much as was done a century ago, the data is remarkable. The Rural Physician Associate Program began in 1971. Students in RPAP spend 9 - 12 months of their first clinical year with a rural preceptor. They see patients and learn about their diseases as opposed to seeing diseases and occasionally meeting the patient. They work closely with their preceptor, but also pursue study of the doctor-patient relationship, ACLS, basic trauma support, and substance abuse. Faculty travel to the site to ensure that education is the top priority for the students. Students in RPAP choose family practice, primary care, and rural practice locations. When students are admitted for rural background and primary care interest (Duluth) and then attend long term preceptorships such as RPAP, over 80 % enter family practice and

In twenty-three measurements RPAP students outperform non-RPAP students in 19. RPAP students are preferred by residency directors. Students on preceptorships explore the community, other health disciplines, practice management, public health issues, and more. They relate with mature people and become more mature. This is a stark contrast with academic medicine where students relate only to each other and individuals who are chasing personal goals.

Syracuse developed its own RPAP program with the help of John Verby. They implemented their program in the 4th year. Their results are similar.

Other items of interest:

  1. RPAP students start out 25% lower than the other students on initial measures.
  2. 60% go to towns of less than 50,000
  3. RPAP students are a greatly valued by program directors and their resident colleagues.
  4. RPAP students are overwhelmed by primary care at 3 months, neutral at 6, and don't want to leave at 9 months
  5. RPAP students actually supply workforce, they are not a burden. Practices bill for thousands more when they have RPAP students.
  6. The RPAP program had to deal with both students and preceptors who were not capable (drugs, alcohol, mental health, etc.) of doing their duties. This is a measure of the interaction.
  7. RPAP students have gone on to become leaders in family medicine in research and service, including the current STFM President.
  8. RPAP depends upon the admissions and educational experiences of the Duluth program where many RPAP students start their medical education (courteousy of Jim Boulger and others). I don't think the value of RPAP is in its rurality, it is in the continuity and involvement of the learning experience. As we face a time in medical education when students seem to observe more and do less, there is another way of learning that is far beyond the model stage.

Duluth students also stay in practice longer, similar to PSAP students from Jefferson.

Arkansas Approach

The Case for Involvement in Rural Communities

Why a Preceptorship Is Better